Cultural psychopathology: uncovering the social world of mental illness

Mental Illness, Gun Access and Carrying: A Test of Competing Hypotheses

Access to firearms among individuals with mental health problems has been a source of protracted debate among policymakers, the media, and the public, writ large. At the center of this controversy are questions about the nature and consequences of gun access in the context of mental illness. The lack of substantial empirical evidence, due in part to limited access to quality data, plays a significant role in perpetuating ongoing debate. To address this problem, this study uses data from the National Comorbidity Survey Replication to evaluate the relative importance of several clinical, cultural, and criminological factors in explaining gun access and carrying among adults with and without mental illnesses. Multivariate analyses reveal that, whereas past year disorder (of any type or severity) and other clinical characteristics were unrelated to firearm access, several cultural factors such as childhood rurality (e.g., ORrural vs. urban: 3.59; 95% CI: 2.52, 5.12) and the criminological experience of early intimate partner violence (e.g., ORvictim only vs. noexp: 1.84; 95% CI: 1.50, 2.26) were. None were predictive of carrying. Further, none of the relationships observed were conditioned on any of the clinical characteristics. These results indicate that people with mental illnesses likely own and carry guns for the same reasons and in the same contexts as others. Additional updated and quality data is needed to further explore these issues; however, these finding suggest that suicide and violence prevention efforts targeting people with mental illnesses need to be sensitive to the cultural and personal significance of guns.

Effects of game-based digital interventions for mental disorders: A meta-analysis

With increasing research attention on game-based digital interventions for mental disorders, a number of studies have been conducted to explore the effectiveness of digital game-based interventions on mental disorders. However, findings from previous research were inconsistent. Thus, we conducted a comprehensive meta-analytic review of the effectiveness of game-based digital interventions for mental disorders. By searching the articles in databases, we identified 53 studies in which 2433 participants were involved, and 282 effect sizes were extracted. Among the 53 studies, 14 employed within-group (pre/post) designs, and the remaining 39 utilized controlled trial designs. Using a three-level random-effects meta-analytic model, a medium effect size of game-based digital interventions (g = 0.47, 95 % CI: 0.33, 0.61) was revealed in the controlled trial designs and a close-to-medium effect size (g = 0.45, 95 % CI: 0.32, 0.58) was found in the within-group (pre/post) designs, indicating close-to-medium-sized efficacy of game-based digital interventions for mental disorders. Moderator analyses showed that age in the controlled trial designs had contributed to the heterogeneity in previous studies, suggesting that interventions might be more effective for the elderly. However, given that only a limited number of studies were focused on the elderly, more studies with older participants should be conducted in the future to provide more robust evidence and explore the mechanisms of how digital gaming interventions can be more effective in improving mental disorders symptoms.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

The impact of anger and self-concealment on post-traumatic stress and psychiatric comorbid symptoms in Chinese prisoners: A longitudinal study

BACKGROUND

Research reported prevalence of post-traumatic stress disorder (PTSD) among prisoners varies between countries, with most studies based on Western samples. The trajectory of symptoms has also been controversial. Trauma can affect prisoners' emotions and their emotional regulation tends to be maladaptive.

AIMS

To examine changes in PTSD and psychiatric comorbidity among prisoners in China over time and to determine whether anger and self-concealment predicts later distress.

METHOD

In a longitudinal, prospective study, sentenced men in one prison in China were asked to complete a demographic page and several self-rating scales: the Post-traumatic Stress Diagnostic Scale, the General Health Questionnaire-28, the Clinical Anger Scale and the Self-Concealment Scale at baseline and at 6 and 12 months after the initial assessment.

RESULTS

More than half of the 496 participating men were diagnosed with PTSD. For those completing the scales at each evaluation, PTSD-DS scores were significantly lower at baseline than at the 6-month and 1-year assessments. No significant differences were found between the two follow-up scores. There was no significant difference in psychiatric comorbidity between the three phases. At the cross-sectional level, after controlling for age and education level, PTSD, anger and self-concealment were associated with psychiatric comorbidity. At the prospective level, anger predicted PTSD 6 months and 1 year later. Self-concealment predicted psychiatric comorbidity over time.

CONCLUSIONS

Among these prisoners the prevalence of chronic PTSD was far higher than in general population estimates. Early identification of aspects of coping styles is likely to help predict disorder trajectory and inform interventions. Early signs of anger were indicative of the chronic severity of trauma reactions, while the intention to hide distress was related to other later mental health problems.

Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

Counseling Across Cultures: A Half-Century Assessment

As the Special Issue of the Journal of Cross-Cultural Psychology celebrates the 50th anniversary of the International Association for Cross-Cultural Psychology (IACCP), this article aims to summarize and track the development of counseling and psychotherapy in cultural contexts over the past half-century. When the edited volume, Counseling Across Cultures (CAC) first appeared nearly half a century ago, it sent an innovative message that culture matters in counseling and psychotherapy. The CAC editors produced six more updated editions in the succeeding years by 2016. The CAC authors examined the cultural context of accurate assessment, meaningful understanding of culture-relevant concepts, and appropriate interventions in each of the seven editions. They have surveyed universal and cultural aspects of counseling and psychotherapy according to such themes as emic and etic approaches to models of mental health, therapeutic relationships and techniques, assessment and interventions, and training needs against the IACCP’s ever-growing academic and professional activities. Research on the cultural adaptation of specific psychotherapies for specific clients should enhance access to culturally sensitive and evidence-based assessments and interventions. The need for training in multicultural awareness is expected to accelerate in the age of rapid globalization. This article affirms the contribution of the foundation-building approaches of CAC and the need for developing the interface between cross-cultural psychology and related clinical and counseling fields.

Cross-cultural adaptation of four instruments to measure stigma towards people with mental illness and substance use problems among primary care professionals in Chile

Stigma toward people with mental illness and substance use problems is a significant global concern, and prevents people with these conditions from accessing treatment, particularly in primary health care (PHC) settings. Stigma is a cultural phenomenon that is influenced by particular contexts and can differ by country and region. The majority of stigma research focuses on Europe or North America leading to a lack of culturally relevant stigma research instruments for the Latin American context. The present study describes and discusses the methodology for cross-culturally adapting four stigma measurement scales to the Chilean context. The cross-cultural adaptation process included nine phases: (1) preparation; (2) independent translations; (3) synthesis 1 with expert committee; (4) focus groups and interviews with researchers, PHC professionals, and PHC users; (5) synthesis 2 with expert committee; (6) independent back translations; (7) synthesis 3 with expert committee; (8) pilot with PHC professionals; and (9) final revisions. The adaptation process included an array of diverse voices from the PHC context, and met three adaptation objectives defined prior to beginning the process (Understandability, Relevance, and Acceptability and Answer Options). The resulting, culturally adapted questionnaire is being validated and implemented within PHC settings across Chile to provide in-depth insight into stigma among PHC professionals in the country. The authors hope it will be useful for future research on mental illness and substance use stigma in similar settings across Latin America.

The Association Between Trauma Centrality and Posttraumatic Stress Among Syrian Refugees: The Impact of Cognitive Distortions and Trauma-Coping Self-Efficacy

While research suggests that the war in Syria has led to a drastic re-evaluation of oneself and elevated psychiatric symptoms among Syrian refugees, little is known whether these psychological reactions might be influenced by maladaptive beliefs about oneself and the world and their ability to cope with the effect of the trauma. This study aimed to provide further evidence on the association between trauma centrality, posttraumatic stress, and psychiatric comorbidity, and examine whether cognitive distortions and trauma-coping self-efficacy would mediate the impact of trauma centrality on distress among Syrian refugees residing in Sweden. Four-hundred seventy-five Syrian refugees completed a demographic page, the Harvard Trauma Questionnaire, General Health Questionnaire-28, Centrality of Event Scale, Cognitive Distortion Scales, and trauma-coping self-efficacy. Results showed that trauma centrality was significantly correlated with posttraumatic stress disorder (PTSD) and psychiatric comorbidity after adjusting the effects of trauma exposure characteristics. Cognitive distortions mediated the impact of trauma centrality on the two distress outcomes; trauma-coping self-efficacy did not but was negatively correlated with outcomes. To conclude, the war in Syria changed self-perception, outlook on life, and identity among Syrian refugees. These changes were related to increased psychological symptoms especially for those who had distorted beliefs about themselves and the world. Refugees' belief in the lack of ability to cope with the effect of the trauma impacted psychological distress independently of changes in self-perception.

Research Trends in Individuals at High Risk for Psychosis: A Bibliometric Analysis

The study of clinical high risk for psychosis (CHR-P) has progressed rapidly over the last decades and has developed into a significant branch of schizophrenia research. Organizing the information about this rapidly growing subject through bibliometric analysis enables us to gain a better understanding of current research trends and future directions to be pursued. Electronic searches from January 1991 to December 2020 yielded 5,601 studies, and included 1,637 original articles. After processing the data, we were able to determine that this field has grown significantly in a short period of time. It has been confirmed that researchers, institutions, and countries are collaborating closely to conduct research; moreover, these networks are becoming increasingly complex over time. Additionally, there was a shift over time in the focus of the research subject from the prodrome, recognition, prevention, diagnosis to cognition, neuroimaging, neurotransmitters, cannabis, and stigma. We should aim for collaborative studies in which various countries participate, thus covering a wider range of races and cultures than would be covered by only a few countries.

What game we are playing: the psychosocial context of problem gambling, problem gaming and poor well-being among Italian high school students

Gambling and gaming are not infrequent among adolescents and preventing low-risk youth from becoming at-risk appears to be a priority of public health strategies. Greater scrutiny of the risk and protective factors in the relationships and community of young people appears crucial in steering prevention initiatives adequately. This study aimed to explore the role of the qualities of relational networks (i.e. family functioning, perceived social and class support), family and peer approval and view of the social environment in predicting problem gambling, problem gaming and overall well-being among adolescents. High-school students aged 14-18 years (N: 595; female: 68,7%) completed a survey including the target variables. A multivariate multiple regression analysis was performed to examine the role of socio-demographic characteristics and psychosocial predictors on gaming, gambling, and well-being. Multivariate multiple regressions identify a common core underpinning problem gambling, gaming and poor well-being but also the distinct roles of psychosocial variables: being male, with low parental monitoring, and an anomic view of the social environment all predict problem gambling and gaming, which were also found to be associated. Low social support predicts problem gambling but not problem gaming; poor family functioning predicts problem gaming but not problem gambling. All the target psychosocial variables, except approval of gambling, predict poor well-being. On the whole the findings suggest the need to look more closely at the way adolescents, their system of activity and their culture participate in constructing the meaning of gambling and gaming activities and their impact on adolescents' well-being, so that future studies and strategies can more effectively examine the relational dynamics in which problem gambling and gaming develop.

The Cumulative and Differential Relation of Adverse Childhood Experiences and Substance Use During Emerging Adulthood

Adverse childhood experiences (ACEs) have far-reaching effects on a wide range of health outcomes in adulthood, however, less is known about their consequences in emerging adulthood or in a geographically distinct sample. We examined the cumulative and individual relation of ACEs and two risky behaviors: alcohol and illegal drugs consumed by 490 Spanish emerging adults (mean age = 18.9). Participants answered the ACEs questionnaire, and two items about alcohol and illegal drugs consumption. Results showed that the overall experience of suffering different ACEs was a significant predictor of drug but not of alcohol consumption. Moreover, ACEs subtypes presented differential effects on substance use. Whereas some increased the likelihood of either drug or alcohol use, others reduced it. This study supports the importance of examining specific adverse experiences rather than only using an overall measure and provides some counterintuitive results that may be linked to resilient mechanisms.

Applying a Process-Oriented Model of Cultural Competence to Behavioral Activation for Depression

Efforts to integrate cultural competence and evidence-based treatments (EBTs) typically take the form of cultural adaptations of EBTs, characterized by modifications to the existing treatment based on presumed cultural notions of a given race or ethnic group. Much less attention has been given to ways EBTs can integrate a process model of cultural competence, which focuses on what clinicians do in-session to identify and integrate key cultural factors for a given individual in the treatment. Our objective is to consider how a process model of cultural competence (Shifting Cultural Lenses) can be integrated with an EBT (Behavioral Activation). We present a theoretical rationale for integrating the SCL model with BA and illustrate this integration, which clinician provides an additional approach to bringing culture to treatments and shows promise for identifying clinicians' in-session behaviors that reflect cultural competence.

Guidelines for Training in Cultural Psychiatry

This position paper has been substantially revised by the Canadian Psychiatric Association (CPA)'s Section on Transcultural Psychiatry and the Standing Committee on Education and approved for republication by the CPA's Board of Directors on February 8, 2019. The original position paper1 was first approved by the CPA Board on September 28, 2011.

The Interrelationship Between Child Abuse, Emotional Processing Difficulties, Alexithymia And Psychological Symptoms Among Chinese Adolescents

This study examined the interrelationship between child abuse, emotional processing difficulties, alexithymia, and psychological symptoms with posttraumatic stress disorder (PTSD) symptoms from past traumas adjusted among Chinese adolescents. Eight hundred adolescents completed questionnaires measuring the preceding psychological constructs. After controlling for PTSD from past trauma, structural equation modeling showed that child abuse correlated with emotional processing difficulty which correlated with alexithymia. In turn, alexithymia correlated with psychological symptom severity. To conclude, child abuse can affect psychological health among Chinese adolescents. This relationship, however, is influenced by the degree to which processing distressing emotions and getting in touch with internal feelings is avoided.

The Participation of Children with Intellectual Disabilities: Including the Voices of Children and Their Caregivers in India and South Africa

There is a shortage of research on the participation of children with intellectual disabilities from middle-income countries. Also, most child assessments measure either the child’s or the caregiver’s perceptions of participation. Participation, however, is an amalgamation of both perspectives, as caregivers play a significant role in both accessing and facilitating opportunities for children’s participation. This paper reports on both perceptions—those of children with intellectual disabilities and those of their caregiver, in India and South Africa. A quantitative group comparison was conducted using the Children’s Assessment of Participation and Enjoyment (CAPE) that was translated into Bengali and four South African languages. One hundred child–caregiver dyads from India and 123 pairs from South Africa participated in the study. The results revealed interesting similarities and differences in participation patterns, both between countries and between children and their caregivers. Differences between countries were mostly related to the intensity of participation, with whom, and where participation occurred. Caregiver and child reports differed significantly regarding participation and the enjoyment of activities. This study emphasises the need for consideration of cultural differences when examining participation and suggests that a combined caregiver-and-child-reported approach may provide the broadest perspective on children’s participation.

Cultural Context in DSM Diagnosis: An American Indian Case Illustration of Contradictory Trends

Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) increasingly acknowledge the importance of cultural context for the diagnosis of mental illness. However, these same revisions include evolving diagnostic criteria that simultaneously decontextualize particular disorders such as Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). As a result, the DSM reflects a contradictory role for context in psychiatric diagnosis. The case analysis presented here frames the consequences of this contradictory trend for an American Indian woman with a history of DSM-IV MDD and PTSD, whose diagnostic portrait is substantively altered in light of more recent DSM-5 criteria. Specifically, consideration of this respondent's bereavement-related illness experience suggests that a sociocentric cultural frame of reference, which places high value on interdependent personal relationships, is not well-captured by DSM-5's revised MDD or PTSD criteria, or the newly proposed categories of traumatic bereavement or Persistent Complex Bereavement Disorder. The respondent's illness experience argues for greater recognition of this contradictory diagnostic trend, suggesting a need for future resolution of this tension toward more valid diagnosis for culturally diverse populations.

Defining and assessing key behavioral indicators of the Shifting Cultural Lenses model of cultural competence

Models of cultural competence highlight the importance of the sociocultural world that is inhabited by patients, and the question of how best to integrate sociocultural factors into clinical assessment and intervention. However, one significant limitation of such approaches is that they leave unclear what type of in-session therapist behaviors actually reflect cultural competence. We draw on the Shifting Cultural Lenses model to operationalize culturally competent in-session behaviors. We argue that a key component of cultural competence is the collaborative relationship between therapists and patients, in which therapists shift between their own cultural lenses and those of their clients, as they co-construct shared narratives together. Accordingly, we propose that culturally competent therapist behaviors include accessing the client's views, explicitly presenting their own views as mental health care professionals, and working towards a shared understanding. We further specify the latter set of behaviors as including the practitioner's integration of the patient's view, their encouragement of the patient to consider their professional view, and the negotiation of a shared view. We developed a coding system to identify these therapist behaviors and examined the reliability of raters across 11 couple and 4 individual therapy sessions. We assessed whether the behavioral codes varied in expected ways over the first 3 sessions of 2 therapists' couple therapy as well. Operationalizing the behavioral indicators of the Shifting Cultural Lenses model opens the door to the integration of both process- and content-oriented approaches to cultural competence.

An ethnic-group comparison of caregiver beliefs about early psychotic illness in a UK sample: Implications for evidence-based caregiver interventions

This study aimed to investigate potential ethnic differences in cognitive responses to caregiving in psychosis that might be relevant to the delivery of caregiver interventions for difficulties related to psychosis. We compared cross-sectional outcomes across early-stage caregivers who self-identified as white British (n = 37) and those who self-identified as black African or Caribbean (n = 41) using United Kingdom (UK) census ethnicity criteria. Self-report questionnaires were used to examine caregiver beliefs about psychosis, including the perceived causes, consequences, timeline, the degree of control that patients have over their difficulties, as well as their appraisals of caregiving. Caregivers from black African or Caribbean backgrounds reported a significantly shorter expected duration of illness than white British caregivers. They were also more likely to cite psychosocial causes (e.g., relationship issues), and less likely to cite biological and genetic causes, as their principal explanations for problems. However, overall differences in perceived causes of illness between ethnicities were not significant, despite the power in this sample to detect medium-sized effects. Factors associated with ethnicity may contribute to individual differences in explanatory models of illness and in experiences of caregiving. A degree of sensitivity to the range of views that people might hold about psychosis may help to engage caregivers from diverse ethnic backgrounds.

Including culture in programs to reduce stigma toward people with mental disorders in low- and middle-income countries

Stigma is one of the main barriers for the full implementation of mental health services in low- and middle-income countries (LMICs). Recently, many initiatives to reduce stigma have been launched in these settings. Nevertheless, the extent to which these interventions are effective and culturally sensitive remains largely unknown. The present review addresses these two issues by conducting a comprehensive evaluation of interventions to reduce stigma toward mental illness that have been implemented in LMICs. We conducted a scoping review of scientific papers in the following databases: PubMed, Google Scholar, EBSCO, OVID, Embase, and SciELO. Keywords in English, Spanish, and Portuguese were included. Articles published from January 1990 to December 2017 were incorporated into this article. Overall, the studies were of low-to-medium methodological quality-most only included evaluations after intervention or short follow-up periods (1-3 months). The majority of programs focused on improving knowledge and attitudes through the education of healthcare professionals, community members, or consumers. Only 20% (5/25) of the interventions considered cultural values, meanings, and practices. This gap is discussed in the light of evidence from cultural studies conducted in both low and high income countries. Considering the methodological shortcomings and the absence of cultural adaptation, future efforts should consider better research designs, with longer follow-up periods, and more suitable strategies to incorporate relevant cultural features of each community.

Cultural Scripts of Traumatic Stress: Outline, Illustrations, and Research Opportunities

As clinical-psychological scientists and practitioners increasingly work with diverse populations of traumatized people, it becomes increasingly important to attend to cultural models that influence the ways in which people understand and describe their responses to trauma. This paper focuses on potential uses of the concept of cultural script in this domain. Originally described by cognitive psychologists in the 1980s, scripts refer to specific behavioral and experiential sequences of elements such as thoughts, memories, attention patterns, bodily sensations, sleep abnormalities, emotions and affective expressions, motivation, coping attempts, and ritualized behaviors that are relevant to posttraumatic adjustment. We differentiate between experiences of traumatic stress that are scripted (e.g., cultural explanations are available) versus unscripted. Further characteristics such as script tracks, the effect of script interruptions, and contextual fit of scripts with other cultural models are also described. We consider examples of traumatic stress associated with war and organized, sexualized violence from "Western" and "non-Western" world regions. The concluding part of this review describes a number of possibilities for methodological approaches to assessment of cultural scripts. Capturing central elements of the script(s) of trauma would aid psychological researchers and clinicians in understanding the experiences of trauma in cultural context, which could ultimately lead to better clinical service opportunities worldwide.

Family processes and duration of untreated psychosis among US Latinos

AIM

Little is known about family processes and treatment seeking among Latinos with first-episode psychosis (FEP) living in the United States. This study examined family processes prior to treatment and their relation to duration of untreated psychosis (DUP) among Latinos with FEP and their family caregivers.

METHODS

Thirty-three Latinos with FEP and their low-acculturated family caregivers (n = 33) participated in qualitative semi-structured interviews focused on treatment-seeking experience and family relationships. Transcripts were analysed using thematic analysis and themes were grouped based on short (n = 18) or long (n = 15) DUP.

RESULTS

Findings revealed differences based on DUP length. Patients with short DUP had stronger family relationships characterized by open communication and disclosure of symptoms that facilitated awareness and direct action by family caregivers. However, patients with long DUP had more troubled family relationships that often challenged early treatment seeking.

CONCLUSIONS

Findings highlight the relevance of family context in the provision of early treatment for Latinos with FEP. Family-based services are needed that increase awareness of symptoms and provide families with support that can facilitate ongoing patient treatment during this critical period.

Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision

This article examines the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its claim of incorporating a "greater cultural sensitivity." The analysis reveals that the manual conveys mixed messages as it explicitly addresses the critique of being ethnocentric and having a static notion of culture yet continues in a similar fashion when culture is applied in diagnostic criteria. The analysis also relates to current trends in psychiatric nosology that emphasize neurobiology and decontextualize distress and points to how the DSM-5 risks serving as an ethnic dividing line in psychiatry by making sociocultural context relevant only for some patients.

Concepts of mental disorders in the United Kingdom: Similarities and differences between the lay public and psychiatrists

BACKGROUND

The lay public often conceptualise mental disorders in a different way to mental health professionals, and this can negatively impact on outcomes when in treatment.

AIMS

This study explored which disorders the lay public are familiar with, which theoretical models they understand, which they endorse and how they compared to a sample of psychiatrists.

METHODS

The Maudsley Attitude Questionnaire (MAQ), typically used to assess mental health professional's concepts of mental disorders, was adapted for use by a lay community sample (N = 160). The results were compared with a sample of psychiatrists (N = 76).

RESULTS

The MAQ appeared to be accessible to the lay public, providing some interesting preliminary findings: in order, the lay sample reported having the best understanding of depression followed by generalised anxiety, schizophrenia and finally antisocial personality disorder. They best understood spiritualist, nihilist and social realist theoretical models of these disorders, but were most likely to endorse biological, behavioural and cognitive models. The lay public were significantly more likely to endorse some models for certain disorders suggesting a nuanced understanding of the cause and likely cure, of various disorders. Ratings often differed significantly from the sample of psychiatrists who were relatively steadfast in their endorsement of the biological model.

CONCLUSION

The adapted MAQ appeared accessible to the lay sample. Results suggest that the lay public are generally aligned with evidence-driven concepts of common disorders, but may not always understand or agree with how mental health professionals conceptualise them. The possible causes of these differences, future avenues for research and the implications for more collaborative, patient-clinician conceptualisations are discussed.

The role of school race/ethnic composition in mental health outcomes: A systematic literature review

INTRODUCTION

This systematic literature review provides evidence concerning the association of school race/ethnic composition in mental health outcomes among adolescents (ages 11-17 years). A range of mental health outcomes were assessed (e.g., internalizing behaviors, psychotic symptoms) in order to broadly capture the relationship between school context on mental health and psychological wellbeing.

METHODS

A search across six databases from 1990 to 2018 resulted in 13 articles from three countries (United States, United Kingdom, and the Netherlands) that met inclusion criteria following a two step review of titles/abstracts and full-text.

RESULTS

The existing research on school race/ethnic composition and mental health point to two distinct measures of school composition: density-the proportion of one race/ethnic group enrolled in a school, and diversity-an index capturing the range and size of all race/ethnic groups enrolled in a school. Overall, higher same race/ethnic peer density was associated with better mental health for all adolescents. In contrast, there was no overall strong evidence of mental health advantage in schools with increased diversity.

CONCLUSIONS

Theoretical and methodological considerations for future research towards strengthening causal inference, and implications for policies and practices concerning the mental health of adolescent-aged students are discussed.

Lessons Learned in Clinical Research Recruitment of Immigrants and Minority Group Members with First-Episode Psychosis

Recruitment of immigrants and racial and ethnic minorities with first-episode psychosis (FEP) for research studies presents numerous challenges. We describe methods used to recruit 43 U.S. Latinos with FEP and their family caregivers (n = 41) participating in a study to reduce duration of untreated psychosis. A key challenge was that patients were not continuing treatment at an outpatient clinic, as initially expected. To facilitate identification of patients prior to outpatient care, we collaborated with clinic and hospital administrators. Many patients and families were grappling with the aftermath of a hospitalization or adjusting to a diagnosis of a serious mental illness. A considerable amount of time was devoted to addressing participants' concerns and when possible, facilitating needed services. Our experience underscores the importance of establishing long-term relationships through multiple contacts with patients, families, and stakeholders to address recruitment barriers among underserved groups with FEP.

The impact of past trauma on psychological distress among Chinese students: The roles of cognitive distortion and alexithymia

Past traumatic events are distressing experiences which can result in the emergence of posttraumatic stress disorders (PTSD) and other psychological symptoms among university students. However, little is known as to whether or not cognitive distortion and alexithymia would influence the severity of these distress outcomes. This study examined a cognitive-emotional framework depicting potential roles that cognitive distortion and alexithymia could play in influencing the relationship between past trauma and psychiatric co-morbidities among university students in China. One thousand one hundred and eleven participants completed the PTSD Checklist for DSM-5, Cognitive Distortion Scale (CDS), Toronto Alexithymia Scale (TAS-20), and General Health Questionnaire (GHQ-28). Results indicated that PTSD following past trauma was significantly associated with increased psychiatric co-morbidities after controlling for covariates. Both alexithymia and distorted cognition mediated the association between PTSD and psychiatric co-morbidities. To conclude, university students can develop PTSD from past trauma and other mental health problems. The severity of psychological distress can be influenced by their distorted perceptions of themselves, the world, and the future, as well as their ability to identify, describe, and express distressing emotions.

Examination of cultural competence in service providers in an early intervention programme for psychosis in Montreal, Quebec: Perspectives of service users and treatment providers

AIM

To better understand cultural competence in early intervention for psychosis, we compared service users' and service providers' perceptions of the importance of providers being culturally competent and attentive to aspects of culture.

METHODS

At a Canadian early intervention programme, a validated scale was adapted to assess service user (N = 51) and provider (N = 30) perceptions of service providers' cultural competence and the importance accorded thereto.

RESULTS

Analyses of variance revealed that the importance of service providers being culturally competent was rated highest by service providers, followed by visible minority service users, followed by white service users. Providers rated themselves as being more interested in knowing about service users' culture than service users perceived them to be.

CONCLUSIONS

Service users accorded less import to service providers' cultural competence than providers themselves, owing possibly to varied socialization. A mismatch in users' and providers' views on providers' efforts to know their users' cultures may influence mental healthcare outcomes.

Measuring Depression in a Non-Western War-Affected Displaced Population: Measurement Equivalence of the Beck Depression Inventory

Depression is commonly seen in survivors of conflict and disaster across the world. There is a dearth of research on the validity of commonly used measures of depression in these populations. Measurements of depression that are used in multiple contexts need to meet measurement equivalence, i.e., the instrument measures the same construct in the same manner across different groups. The Beck Depression Inventory (BDI) was administered to female trauma survivors in the United States (n = 268) and female survivors of war in Sri Lanka (n = 149). Three metrics of measurement equivalence—structural, metric, and scalar—were examined. Two- and three-factor structures of the BDI that have been identified in other populations did not provide a good fit for our data. However, a bifactor model revealed a similar general distress dimension across populations, but dissimilar secondary dimensions or subfactors. The Sri Lankan subfactor comprised of predominantly somatic symptoms and the United States subfactor comprised of cognitive and somatic symptoms. While intercepts of individual BDI items differed, their differences seem to be offsetting. Total BDI scores across these two populations are roughly comparable, although caution is recommended when interpreting them. Making comparisons on subscales is not recommended.

Intersecting Cultures in Deaf Mental Health: An Ethnographic Study of NHS Professionals Diagnosing Autism in D/deaf Children

Autism assessments for children who are deaf are particularly complex for a number of reasons, including overlapping cultural and clinical factors. We capture this in an ethnographic study of National Health Service child and adolescent mental health services in the United Kingdom, drawing on theoretical perspectives from transcultural psychiatry, which help to understand these services as a cultural system. Our objective was to analyse how mental health services interact with Deaf culture, as a source of cultural-linguistic identity. We ground the study in the practices and perceptions of 16 professionals, who have conducted autism assessments for deaf children aged 0-18. We adopt a framework of intersectionality to capture the multiple, mutually enforcing factors involved in this diagnostic process. We observed that professionals working in specialist Deaf services, or with experience working with the Deaf community, had intersectional understandings of assessments: the ways in which cultural, linguistic, sensory, and social factors work together to produce diagnoses. Working with a diagnostic system that focuses heavily on 'norms' based on populations from a hearing culture was a key source of frustration for professionals. We conclude that recognising the intersectionality of mental health and Deaf culture helps professionals provide sensitive diagnoses that acknowledge the multiplicity of D/deaf experiences.

Emotionally triggered asthma and its relationship to panic disorder, ataques de nervios, and asthma-related death of a loved one in Latino adults

OBJECTIVE

Research has demonstrated high comorbidity between asthma and panic disorder (PD). Less is known about the relationship between asthma and the Latino cultural idiom of distress of ataques de nervios, as well as the role that psychosocial stressors play. The current study tested the hypotheses that Latino asthma patients who experience PD, ataques de nervios, and/or asthma-related death of a loved one endorse greater psychological triggers of asthma, greater perceived impact of asthma triggers, and greater difficulty controlling such triggers than do those without these conditions.

METHODS

Data originated from an interview conducted prior to a randomized controlled trial in which 292 Latino adults with self-reported asthma were recruited from outpatient clinics in the Bronx, NY. The PRIME-MD Patient Health Questionnaire (PHQ) was used to screen for PD symptoms, while the Structured Clinical Interview for DSM-IV (SCID-I) was used to confirm diagnosis of PD. Lifetime history of ataques de nervios and asthma-related death of a loved one were based upon self-report. Asthma triggers were examined using the Asthma Trigger Inventory (ATI).

RESULTS

PD, ataques de nervios, and asthma-related death of a loved one each predicted a higher frequency of psychological asthma triggers, controlling for gender and comorbid medical conditions. Participants with PD also reported greater impact of asthma triggers than those without PD, while no significant differences in perceived control were observed.

CONCLUSION

Providers should screen for PD, ataques de nervios, and asthma-related death of a loved one in Latino asthma patients, given their observed association with emotionally triggered asthma.

Vietnam as a case example of school-based mental health services in low and middle income countries: Efficacy and effects of risk status

The purposes of this study were to (a) assess the efficacy of a universal classroom-based mental health and social skills program for primary school students in Vietnam, and (b) given the universal nature of the intervention, assess outcomes as a function of risk status (high vs. low). RECAP-VN is a semi-structured program that provides students with classroom social skills training, and teachers with in-classroom consultation on program implementation and classroom-wide behavior management. Project data were collected at three time-points across the academic year from 443 2nd grade students in regards to their social skills and mental health functioning, in the Vietnamese cities of Hanoi and Danang. Mental health functioning (emotional and behavioral mental health problems) was the ultimate outcome target (at Time 3), with social skills intermediate (at Time 2) outcomes targeted to improve mental health functioning. Significant treatment effects were found on both social skills and mental health functioning. However, although program effects on mental health functioning were significant for both low and high risk status groups, program effects on social skills were only significant for low risk status students, suggesting that different mechanisms may underlie program effects for high and low risk status students. Overall the results of this study, one of the first to assess directly the effects of a school-based program on mental health functioning in a low or middle income country, provide some support for the value of using school-based programs to address the substantial child mental health treatment gap found in low- and middle-income countries.

A Comparative Study of Values and Attitudes of Inner-City and Middle-Class Postpartum Women

This study compared postpartum women from the inner city ( n = 94) and postpartum women from the urban middle class ( n = 80) on values and goals for themselves and their newborn children. Terminal values of inner-city women for themselves related more to social and religious goals in contrast to the more intrapersonal and personal goals of middle-class women. Instrumental values of inner-city women for their newborn children demonstrated concern with conformity and control, whereas for the middle class there was more concern with competence. Goals for the near future of the inner-city mothers were based on a desire for jobs and education.

Coping as a Mediator Between Losing Face and Depressive and Social Anxiety Symptoms Among Asian Americans

Applying the proximal–distal framework, we were interested in whether the relationship between loss of face (LOF) concerns to depression and social anxiety were mediated by coping among 154 Asian Americans (AA). Utilizing a convenience sample from an online survey of AA, we ran ordinary least squares (OLS) regressions to examine whether direct and indirect coping explained the relationship between LOF concerns, depression, and social anxiety. LOF was positively associated with both direct and indirect coping. LOF also was positively associated with depression and social anxiety. The relationship between LOF and depression was significantly mediated by indirect coping but not direct coping. Higher levels of indirect coping explained the relationship between LOF and depression. In addition, the relationship between LOF and social anxiety was significantly mediated by indirect coping and direct coping. The relationship between LOF and social anxiety was partially explained by lower levels of direct coping and higher levels of indirect coping. LOF, however, continued to significantly predict social anxiety even after accounting for coping strategies. These results suggest that the LOF has a distal relationship to depression and social anxiety. Coping has a more proximal relationship to depression and social anxiety. By identifying proximal factors to depression and social anxiety, it is possible to reduce symptoms of depression and social anxiety among AA without mitigating the endorsement of traditional cultural values.

The Equivalence of the Behavior Problem Index Across U.S. Ethnic Groups

In this study, the authors examine the equivalence of the factor structure of a commonly used symptom checklist of behavioral and emotional problems—the Behavior Problem Index (BPI)—across African American, Hispanic, and White children in the United States. The sample is drawn from the 1998 data file of the Children of the National Longitudinal Survey of Youth, a U.S. data set. The results of the study suggest that the BPI is not equivalent across the three ethnic groups. These findings are consistent when equivalence is tested for a one-factor model, a two-factor model using the internalizing and externalizing dimensions of the BPI, and a six-factor model using the subscales of the BPI. Item-level analyses identify the statistically significant items that are associated with nonequivalence across ethnic groups. The implications of nonequivalent measures for cross-cultural research and practice with families and children are discussed.

A Quantitative Analysis of Ataque de Nervios in Puerto Rico

The authors present a quantitative analysis and assessment of the symptoms of ataque de nervios. A sample of 121 individuals living in Puerto Rico provided qualitative and structured data on ataques de nervios and psychiatric correlates. A total of 77 participants reported having an ataque de nervios during their lifetimes. Their reports of symptoms associated with the ataque-episode were analyzed using factor analysis. Two dimensions emerged from the analysis, representing respectively internalizing and externalizing experiences. Results sustained the heterogeneity of ataque de nervios with a marked anxiety component. The authors discuss results in the context of classification and understanding of ataques de nervios and a model for studying cultural variance among cultural syndromes.

Latino Cultural Differences in Maternal Assessments of Attention Deficit/Hyperactivity Symptoms in Children

Many aspects of attention deficit/hyperactivity disorder (ADHD) are likely influenced by culture, particularly the differences in perceptions of child behavior and the demands of the environment in homes, schools, and communities of people from different ethnic and cultural groups. In particular, ADHD-related behaviors must be understood within the context of cultural environments and expectations. This study examined differences in parental evaluations of ADHD-related child behaviors in the following three Latino ethnic populations: Mexican ( n = 81), Mexican American ( n = 179), and Puerto Rican ( n = 60). Overall, results indicate an important role for acculturation in mothers’ perceptions of ADHD-related behaviors but only in the measures of hyperactivity and not in the attention deficit aspects of the disorder. Mothers from different Latino cultures and at different levels of acculturation differentially assess specific symptoms of ADHD, indicating the need for careful reassessment of the validity of the disorder for Latino families.

An Inquiry Into the “Agonies” (Agonias) of Portuguese Immigrants From the Azores

Previous research has found that psychiatric symptom expression is inextricably linked with culture and that psychiatric categories do not necessarily reflect the experiences of people from other cultures. Using a multidisciplinary approach, this study explored the Portuguese culture-specific phenomenon agonias (meaning “the agonies”). Fifty (21 males and 29 females) Portuguese immigrants from the Azores were interviewed concerning their immigration experience, family life, health, healing, suffering, and understanding of agonias. Although there was diversity among the participants’ responses, a cohesive and systemic understanding of agonias arose from the narratives. A link between the somatic symptoms of agonias and psychological processes, social context, and religious beliefs was demonstrated, and highlighted that psychiatric categories are limited when classifying a multidimensional experience like agonias.

Assessing Adolescents' Understanding of and Reactions to Stress in Different Cultures

This article expands on an emerging mixed-method approach for validating culturally-specific constructs (see Hitchcock et al., 2005). Previous work established an approach for dealing with cultural impacts when assessing psychological constructs and the current article extends these efforts into studying stress reactions among adolescents in Sri Lanka. Ethnographic data collection and analysis techniques were used to construct scenarios that are stressful to Sri Lankan youth, along with survey items that assess their related coping mechanisms. The data were factor analysed, results were triangulated with qualitative findings, and reliability estimates of resulting scales were obtained. This in turn generated a pilot assessment approach that can be used to measure stress and coping reactions in a distinct culture. Use of the procedures described here could be replicated to generate culturally-specific instruments in international contexts, or when working with ethnic minorities within a given nation. This should in turn generate information needed to develop culturally relevant intervention work.

Implications of an Emerging Integration of Universal and Culturally Specific Psychologies

Psychological researchers increasingly recognize that human behavior reflects a complex interplay of universal human capacities, cultural responses to unique histories and circumstances, and individual differences. Many psychological processes appear to reflect culturally specific instantiations of universal capacities. Current integrative research focuses on further clarifying definitions of universality and on refining methods for identifying universal and cultural components of psychological processes. In this article, we consider implications of this emerging integration. To illustrate possible implications for psychology, we apply it to the study of psychopathology. We report on formal models that explain why some cultures embrace dysfunction among members. We then use the integrative framework to describe methods for determining whether putative disorders bring universal or contextual life dysfunction and to clarify etiological models of three disorders. Models of psychopathology can be more informed and precise if they include careful consideration of both universal and cultural influences on behavior.

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth's mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: 1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth's mental health problems are misdiagnosed? 2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included "race", "ethnicity", "minority", "culture", "children", "youth", "adolescents", "mental health", "psychopathology", "diagnosis", "misdiagnosis", "miscategorization", "underdiagnosis", and "overdiagnosis". Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth's emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.