Global Mental Health midterm
Challenges with defining Mental Disorders
****Parity = equality -hard to make physical & mental issues equal bc MH has so much ambiguity vs physical diseases have biomarkers -Controversies persist; is it moral judgment or a real disease? -diff budgets allocated across countries -when do symptoms, i.e. anxiety, rise in severity and become a disorder? --> challenge defining to diagnose. When it impairs functioning Multiple contributing causes - not fully understood the role each plays
Journalling: What is culture? Meaning is not something internally generated but instead is something that is given to us through the language and culture into which we are born
*MH can be very personalized based on experience and culture Advancing GMH requires understanding the interaction of psychopathology with diverse types of social structure & process
Is western approach to PTSD conceptualization and intervention right/wrong?
*imposing cultural beliefs * issue of sustainability when we try to deliver MH interventions globally Is the culture always right? Trauma & Children.... what about palestine? don't believe in PTSD but have high suicide rate and won't accept our depression scale female genital cutting?
How do we measure 'culture'
*use geographic location *US census (ethno-racial) Pressure to deliver interventions ----view cultural differences as temporary obstacles that can be overcome by education or mental health literacy Examples of idioms that don't make any sense to others? → display cultural differences
journalling: "People could be healed if they were able, truly and deeply, to believe that they would be healed"
- Duality between Biological vs. Psych and Environmental -A lot of difficulty in finding the right treatment for each person -For example, once someone develops schizophrenia, their mental state is so out of their hands and their paranoia can take over to the point where they are not able to believe realistically in general -Commonly used terms to stigmatize, even if unintentional, people living w/ mental illness
How culture influences MH
- Perception, experience, & explainaion of symptoms, suffering and well-being -Modes of expression of distress -Patterns of coping and help-seeking -Strategies for healing and treatment intervention -Social consequences of symptoms, functional impairment and diagnostic labels
Role of Mental Health Systems
- Romania example "Who Belongs in a Psychiatric Hospital" by Friedman Over Medicalization of mental illness, throughuse of meds & pathologizing of social problems Romanian psychiatric hospitals have functioned where families & states dump people with developmental or cognitive disabilities Treat this people strictly with meds, not therapy; do not have psychotherapy or a lot of psychologists So Psychiatric hospital cares for all "brain disorder" Lack of outpatient care; double the amount of psychiatry beds in the US High, double than US, admissions to psychiatric hospitals & beds Treating medical & social problems in largely institutionalized settings throughout socialist europe
US States MH Services
- States = significant power in making decisions about their MH systems; vary state to state • State MH systems must meet certain standards set by the fed govt, but free to expand past that • freedom to experiment w innovative services and delivery models allows states to create improvements that can ultimately be translated across the country!!
Burden of mental illness underestimated. Why?
- Stigma embodied in social structures, policy, legislation -the overlap between psychiatric and neurological disorders -grouping of suicide and behaviours associated with self-injury as separate category from Mental illness -excluding personality disorders -inadequate consideration of the contribution of severe mental illness to mortality from associated causes.
Why does mental health matter to global health
- burden: 300-400 million affected, worldwide leading cause of death in teens is suicide, life expectancy is 20 years shorter in those w mental illness -lack of treatment: HIC, up to 50% go without treatment LIC, up to 90% go without treatment -abuse: often in institutions that are supposed to treat
Depression & Zulu
- difference in depression among cultures -in zulu, there is not even a word for depression - people suffer in silence because of the stigma -Because there is often an absence of physical symptoms with mental illness, it is considered 'not real',
Classifying disorders on a spectrum
- disorder intensity varies at different times, so screening important at different intervals -Role of clinical judgement in where to this cutoff along symptom dimension and cultural factors ------- is what constitutes a disorder in one setting same in another?1!!??? Differentiating health from disorder... a tricky business
Role of Biological factors in MH
- genetics, & our interactions - infections (not causal to MH, just connected) -brain defect/injury -prenatal damage (i.e. autism) -substance use -nutrition (exposure to lead)
Consequences of Mental Disorders
- human rights violations - limited participation in social life - difficulties in work contexts - increased risk of physical, emotional and sexual abuse - higher mortality rates than rest of population
Complications of Access to MH globally
- insurance & money - stigma - transportation - resources in health care - language barrier - ongoing/ engaged long term care - awareness of services - poverty/time -adequately trained professionals
Journaling: problem faced by social sciences = measurement. How does this apply to psychology and mental health?
- measuring psychological distress is not concrete/quantifiable -hardship in measuring the actual gravity of mental illness -also no universal way
Journalling: Do mental disorders, as currently conceived, reflect social and moral values of the dominant powers within the MH community, a community that is still essentially Western-dominated, or do they capture universal or global concepts of disordered states?
- mental disorders can reflect cultural values, most especially with the victim's perception of what is causing the mental illness -DSM-5 : what is accepted or not based on what's socially accepted in the western realm -Different doctors define treatments differently -Romania example → they see western ideology as over-medicalization
Why does Post-Partum Depression (PPD) matter?
- perinatal period (pregnancy & one year postpartum) CRITICAL time for developmental life course of child -women more likely to develop depression/anxiety @ this time -Mental disorders during perinatal period affect 7-15% of women in HIC & 16-25% in LMIC - Up to 50% PPD Incidence, attributable to cultural factors like varying definitions and expression of symptoms -Poor MH hinders ability for affected women & child to achieve optimal health, human development & well being -PPD most common child birth related complication in U.S.
Different ways to address MH in surveys
- specific survey on the topic (of specific disorders) - surveys including instrument on one specific mental disorders - surveys w 1-2 questions investigating only depression/anxiety/others looking at chronicity - Surveys with Qs on mental disorders to evaluate differences in some areas (e.g. employment, economic conditions ...) between people with and without
Importance of Diagnosis
- to identify as early as possible and determine the treatment needed - Communication between groups (when reliable, valid, and applicable across settings) - common language globally to talk about things -
Everyone has own experiences and culture and personalized views of things,ie mental health - so how does this impact GMH?
-Contributes to health disparities, structuring inequalities and the distribution of health problems and resources -Influences symptomatology, course and outcome of disorders -Shapes individual and family coping and adaptation to illness and Recovery -Undergirds the clinician-patient relationship and patient's response to medical advice and intervention -Frames the values, alternatives and outcomes that inform health care decision-making -***deterimes help-seeking: huge gap in treatment provision globally (75-90%) don't seek help, many reasons why, but impacts you going to get help
Instruments of data for MH
-Diagnosis of MH disorder Self report scales asking about symptoms observation by clinician Common scales used in surveys CIDI, CES-D, K6 K10 -may need to elaborate here
New research about MH & biology
-MH genes unique to humans -.... look @ notes i don't get it
global mental health's role in diagnosis
-Mobilization of resources to meet these challenges in the ways we can ex)task shifting -striving for equity -Not at odds with diagnosis, common language across cultures is essential ACCEPT WESTERN MODEL IS NOT A FIT FOR ALL& not all diagnosis is absolute
Study of former child soldiers: Role of Resilience & PTSD
-Researchers found child soldiers with PTSD who demonstrated high resilience scores showed CTRA gene expression markedly lower than those with average or low resilience This suggests that PTSD did not impact CTRA gene expression among highly resilient children Kohurt suggests: Interventions to promote resilience can be delivered more easily than specialized PTSD treatments in post-conflict and post-disaster settings, and our study raises the hope that resilience-focused interventions could change the genetic response to childhood trauma."
Infant and Early childhood: Still face experiment
-Study on emotional attachment in early childhood -Considerable impact on later vulnerability to mental health -Risk factors include: separation from caregiver, and parents for whom communication & social interaction is challenging
What is culture?
-Way of life, identity, tradition of a specific group or communit -socially constructed facts with impacts on health & wellbeing !!! Culture transmitted across communities AND time
Barriers to accessing MH care services among women
-economic barriers -lack of awareness about MH issues -stigma associated w Mental Illness -lack of time/related support -lack of appropriate intervention strategies *including integrating MH services into PHC
Anorexia in China
-explain how hard it is to access support for binge-eating disorder, bulimia and anorexia, because of attitudes to food and weight, taboos around mental health, and a lack of treatment options. - describe the pressure on women to be 'small' and 'diminutive', but still take part in the country's deeply entrenched eating culture. -Does there need to be an abundance of food in a society before these problems develop?
Important to remember implications of stigma and discrimination w MH
-higher level of stigma may leas to poor treatment and discrimination -people w MH conditions face discrimination even in healthcare settings
Why is women's MH different?
-issues unique to women -diseases more prevalent in women -diseases expressed/symptoms/manifest differently in women -respond indifferently to interventions -barriers to access -bias in the medical professions RATES - 2x higher in women for depression LIFETIME women (21%) men (12%) - depression leading cause of disability world wide -anxiety 2-3x higher in women -90% of eating disorders in women
Deaths from Mental illness
-play a role in underestimation of severity Direct deaths - eating disorders & substance use which is low Indirect deaths - suicide *** not always attributed to mental disorders
History of Mental Illness
-progression overtime -witchcraft and possession -psych disorders=dangerous -mentally ill in society but still see as mad -lunatics = weak minded -19th & 20th century: disciplinary treatments abolished & investment made to understand MH as a health issue ***• A shift from "bad nerves" to examining all possibly relevantinformation (family history, key life events, perception, etc.). Movefrom discrete disease to continuum. In the words of Meyer "failure to adjust to life's demands...humans are biological organisms withinherited strengths and weaknesses, but every patient is an individualwith unique life history.
Why do women have higher rates of MH issues?
1) Biological vulnerability: hormonal, physiological, reproductive-related events 2) Psychosocial factors: gender roles, violence, low SES, stress, caregiving responsibilities 3)Economic and social 'shaping' policies
"Common Language" of Mental Health
1. DSM-5: Categories and diagnostic criteria; primary mode used to diagnose mental disorders globally -primary mode used to diagnose mental disorders globally 2.ICD-10 International Classification of Disorders - Mental Disorders -published by WHO -Used primarily to code disorders for reimbursement claims for health insurance
Most prevalent diseases
1. anxiety 3.76% 2. depression 3.44% 3. alcohol use 1.4% 4. drug use .94
Top 5 global mental health challenges
1. integrating MH services into PHC 2. how to reduce cost of meds and improve supply of effective meds 3. provide effective & affordable rehab & care in communities 4. improve access to effective care for kids in LMICs 5. strengthen MH training for all health-care workers
Do checklists reflect culture? Do harm? Sri Lanka ex
26 item list Sri Lankans experienced aches and pains (chest/muscles) reacted as if they had been physically harmed (somatic); didn't experience as anxiety but saw it more related to social networks (not inside their mind, but outside the self).
WHO's conceptualization of MH
3 groups: 1. individual attributes & behaviors 2. Social & economic circumstances 3. Environmental circumstances *Lists adverse & protective factors of each
Mental and behavioral disorders due to psychoactive substance use
Acute intoxication; harmful use; dependence syndrome; withdrawal state; psychotic disorder; amnesic syndrome; residual and late- onset psychotic disorder; other and unspecified
PTSD - A western conception?
An individual is thought to have a problem processing the traumatic material and healing - professionals work to promote such processing. Current model locates the problem inside the mind; established way of conceptualizing how human beings respond to hurtful life events '
Discuss assumptions Wentz and others made about the nature of psychological Trauma for Sri Lanka (post tsunami)? → largest psychological intervention
Assumed PTSD has the same manifestation everywhere Treated with same approach as US PTSD Sri Lanka did not have their own way of treating PTSD Needed Immediate intervention after the tsunami Psychological reaction is fundamentally the same around the world. U.S. had more and better resources to respond to the mental health crisis Clustering of symptoms; pathological Increase in PTSD and depression as a given Risks of suicide for those impacted by PTSD Add to psychological burden Need a sophisticated health system to respond Need for psychological treatment services would overwhelm the region - would not be able to manage
Adolescence & Early Adulthood: WHO surveys MH of international college students
Colleges have rising rates of MH and higher demand for services on campus *35% in college population globally vs. 17% in general public Shows why its important to target different life stage group - vulnerable for different reasons @ different times
How do you measure someone's appraisal of events?
Current approach in psychiatry: nomothetic -need to count mental disorders using available data....using diagnosis or self-report -often imperfect -use ICD-10 & DSM-5 for specific definitions
The Measurement of Disease Burden
DALYS - Disability adjusted life years 1 DALY= 1 lost year of a healthy life - years of life lost to disability -Composite measure of death + years of living with a disability YLDs - years lived with disability
Organic, including symptomatic, mental disorders
Dementia, mental disorders and behavioral disorders due to brain injury and damage
U.S. Mental Health System
Federal V. State Powers in MH system MH very state dependent; MH gets funded through statepublic funding States have most decision-making power for each state; have to meet federal guidelines MA not progressive in MH; huge gaps in care with funding in MH and physical health Federal gives for research and innovation, major funding for MH services, protecting the rights of customers, regulating systems
Journalling: How would you describe the ethos of women's MH in the US? Globally?
Flawed, stigma, 'hormones', incorrect diagnosis, health system design issues
Measuring MH at the population level
MH overall super complex construct to measure USE: -administrative records (not viable for LMICs) -differences in national legislation & regulation can cause significant gas when comparing countries -population surveys (but high level of stigma -differences in purpose, instruments, data collection
Mood Disorders
Manic episodes bipolar affective disorder depressive episode persistant mood disorders recurrent depressive disorder
Challenge of MH History
No NATURAL history of mental illness - we want to know what CAUSES mental illness
Nomothetic v. Idiographic approaches to psychiatry
Nomothetic: explanations based on general scientific laws - research based? ***mostly used in psychiatry: objective definitions, quantifiable variables, statistical generalizations Idiographic: explanations based on historical sequences that only occur once- looks at an individuals unique events - less commonly used and accepted -" a psychology of an individual is idiographic"
Underestimation = huge
People really slip through the crack when we try to evaluate MH globally ****Mental disorders are a major driver of the growthof overall morbidity and disability globally. 970 million-1 billion people worldwide had a mental or substance use disorder in 2017 (estimated)
What Psychological & Environmental factors is Biological Susceptibility to mental illness combined with?
Psychological Factors (not comprehensive) -severe trauma in childhood -early loss -neglect -difficulty relating to others Environmental Factors -death -divorce -low self esteem, anger, loneliness, -dysfunctional life at home -social & cultural expectations -substance use
Response to PTSD in Sri lanka
Response to dire warnings: gather resources; send army of trauma counselors to address impending epidemic of PTSD Largest international psychological intervention - clinicians from high income countries, to bring mental health care into modern era Psychological first aid is new Didn't ask if PTSD could be usefully applied in all different cultures? How others conceive of self? Implicit and explicit assumptions Speedy interventions are crucial
Resilience in Sri Lanka
Sri Lankans better able to give meaning to violence and deprivation western counselors were actually the ones struggling Role of religion; shared ethnocultural belief - practices that might steady people in the aftermath of trauma ****Example of the boy - what mother said to him, togetherness in the face of violence and death What does this mean for approaches to treatment?
Western vs Sri Lankan approach to cause and effect of PTSD?
Sri lanka Interwove the social & the psychological symptoms A 'social' cause & effect Self & identity as part of a social group Mind & body connection Western conception assumes the problem is in the mind, overlooks most salient symptoms for Sri Lankan that exist in the social realm -underplaying the role of religion and spirituality (belief systems)
Crazy Like Us audios
The wave that brought PTSD to Sri Lanka
Other approaches to PTSD
Trauma-related distress is not the inevitable outcome of traumatizing event. PTSD is part of a complex network of post-conflict ecosocial adversity in which socioeconomic AND political contexts interact with mental health
Interventions & approaches (for all Mental Health)
UNIVERSAL APPROACH -screening; a point to start a convo -referral to specialist -lack of resources -access to specialist providers (insurance, ability to pay, knowledge, provider bias)
life course approach
life stages & using these stages to group people & intervene accordingly
Determinants of Mental Illness: where we are today
multiple causes interact, to create people who choose & shape their environments -emphasis on stress & what makes people more "vulnerable" to stress ALSO - resilience research those who move on despite their experiences ...implies there is something inherently wrong with vulnerability Role of situations in causing symptoms is usually identified as stress and stress is measured in terms of life events... ----This ignores how an "individual's appraisal of the meaning of events gives rise to symptoms"
Categories in ICD-10
organic, psychoactive substance use, mood disorders, neurotic & somatoform, behavioral (syndromes), personality, mental retardation, schizophrenia Disorders of adult personality: Paranoid personality, schizoid personality disorder, habit and impulse disorders (gambling, fire- setting), gender identity, disorders of sexual preference • Mental retardation (mild, moderate, severe) • Disorders of psychological development (speech and language); autism • Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (conduct, social anxiety, separation anxiety)
"My Diagnosis" -it's complicated & Imperfect
people just want to be diagnosed with something, but it is not that simple
Behavioral syndromes
• Eating disorders (anorexia nervosa, bulimia) • Nonorganic sleep disorders • Sexual dysfunction • Unspecified behavioural syndromes associated with physiological disturbances and physical factors
Neurotic , stress-related, and somatoform disorders
• Phobic anxiety disorders • Other anxiety disorders (including panic and GAD) • Obsessive compulsive disorder • Adjustment disorders (including PTSD) • Dissociative disorders • Somatoform disorder (body dysmorphic, hypochondriasis)
Representation and Diversity of Clinicians - questions post Sri Lanka psychological intervention
• What role does representation and diversity of mental health clinicians play in this conversation? • With the lack of current representation and diversity in mental health clinicians worldwide, how can governing bodies encourage (or even enforce) clinicians to become more culturally competent, especially in areas with a lot of cultural diversity? • What role do researchers play in shaping clinicians' understanding of different cultural norms?
Schizophrenia
•persistent delusional disorders • Acute and transient psychotic disorders • Induced delusional disorder • Schizoaffective disorders