Launch of the Global Mental Health Program at Â鶹ԼÅÄ, June 2-7, 2016
Global mental health research requires cross-disciplinary skills and knowledge of the social determinants of mental health, and of the interrelations between social inequalities and health outcomes. Research methodologies (both qualitative and quantitative) must be adapted to resource-poor countries, cross-cultural sensitivity and competency in negotiating roles and expectations with collaborating partners based in LMICs. The seminar will provide a cultural critique of GMH and address basic issues for discussion including: (a) the extent to which it is useful to frame mental disorders as brain disorders, neuropsychiatric and psychological disorders, and/or social disorders, and the consequences of each way of framing mental health problems; (b) the extent to which the diagnosis and treatment of psychiatric disorders are generalizable across cultural and social boundaries; (c) the linkages between the social context and mental health outcomes, including poverty and social inequalities; (d) ways in which interventions may be based in or derived from contextually driven forms of problem solving, healing and coping with mental illness; (e) ways of empowering local communities to identify and mobilize endogenous resources, intervention goals and programs; and finally, (f) review case studies presenting innovative policies and interventions for decentralization of health resources and implementation of participatory community-based mental health care. The workshop will include lectures, discussions, case studies and video documentaries.
The Place of Culture in Global Mental Health – Laurence Kirmayer
GMH frames mental health conditions as neuropsychiatric disorders. This implies that problems are located in brain and can be studied and treated in terms of neuroscience. The presentation will consider the ways in which global psychiatry configures treatment and prevention of mental disorders as “clinically applied neuroscience.†We will unpack the assumptions underlying: (i) the neuroreductionist view of mental disorders as located in the brain the brain; (ii) the relevance of cultural variations of distress in recognizing and categorizing mental disorders; and (iii) implications of culture and context for understanding the social determinants of health and the design of public health interventions, mental health services and clinical treatments. Methods for research and clinical intervention that are grounded in culture and community will be discussed.
Global Burden of Disease: What metric approaches contribute – Ross White
This session will critically reflect on the emergence of metrics such as the Disability Adjusted Life Year (DALY) that have been used to quantify the burden of mental health difficulties. This will include a focus on the process by which the DALY is calculated, and the epidemiological assumptions that underlie this process. A range of relevant issues will be discussed including the prioritization given to understanding disease burden from the perspective of individuals rather than communities; challenges associated with international comparisons of disease burden, and a lack of focus on intra-national variation in mental health difficulties (urbanization) need to be considered.
Cultural adaptation of interventions – Ross White
This session will explore efforts that have been made to adapt mental health interventions originally developed in high-income countries (HIC) so that these interventions can be used in low- and middle-income countries (LMIC), or to better engage under-served minority communities in high-income countries. The session will critically discuss the need to adapt interventions to accommodate diverse cultural beliefs and practices. Approaches that have been employed to undertake the process of adaptation will be highlighted. In addition, the session will examine research evidence that has sought to evaluate the efficacy and effectiveness of culturally-adapted forms of interventions for mental health difficulties in both HIC and LMIC.
Child protection and mental health – Mónica Ruiz-Casares
Exposure to adverse childhood experiences, including child abuse and neglect, has been linked to mental health disorders worldwide. In LMICs, there is a research and practice gap in research-supported child maltreatment and mental health prevention and treatment. Nonetheless, scholars and decision-makers are paying increasing attention to child maltreatment and the protection of children from violence, particularly in conflict settings. Parenting programs as well as school and community-based interventions promoting the positive mental health and wellbeing of young people are starting to be developed/adapted and evaluated with variable success. We will discuss the incipient literature on child maltreatment in LMICs, with attention to the transportability of interventions originating in high-income countries and innovative methods used to elicit young people’s perspectives to inform these processes.
Children and Families Affected by Armed Conflict– Myriam Denov
Over the past several decades, there has been a considerable shift in the nature of war and political violence. The increase in internal/civil conflict, the collapse of states, the direct targeting of civilians during conflict, the international proliferation of small arms and light weapons, and the increasingly long duration of conflicts continue to have a transformative impact on the health and well-being of conflict-ridden populations. Although the effects of war and political violence are extensive and widespread, children and families have become increasingly vulnerable, bearing much of the burdens associated with the ongoing violence. Reflecting this complex reality, in this session we will examine the impact of war on children and families. In particular, drawing on case studies in Sierra Leone and northern Uganda, we will explore the realities of child soldiers, as well as the intergenerational effects of wartime sexual violence.
Impact of War and Violence on Mental Health – Hanna Kienzler
In this session, we will critically discuss different approaches to war-trauma and trauma-related health problems. We will begin by taking a closer look at trauma-focused approaches and contrasting them with psychosocial frameworks. This will be followed by an exploration of local idioms of distress through a case study that looks at how Kosovar Albanian women express their suffering focusing on temporal narratives of symptoms, multiple causal relations and, related to these, the modes and concepts of expressing distress. During group discussions, we will think about possible frameworks that could integrate the various approaches and pay attention to multiple biological, psychological and social pathways that influence people’s expressions of distress and suffering.
Humanitarian and mental health aid – Hanna Kienzler
In this session we will examine how researchers envision that short-term humanitarian mental health interventions transition into sustainable post-war community mental health interventions. Furthermore, we will critically explore scientific and contextual factors that shape this transition focusing on culture, social relations, local and global socioeconomic contexts, as well as national and international development agendas. Case studies from Kosovo and the occupied Palestinian territories will be used to illustrate these complex processes.
Women’s Health and FGM – Danielle Groleau
Female genital mutilation (FGM) is a violent and painful traditional procedure mainly performed on minors and under the authority of their primary care givers. The potential magnitude of eventual psychological and mental health effects is huge, given that in Africa alone, which is where FGM is most prevalent, it is estimated that 92 million girls 10 years of age and older have undergone FGM (Yoder et al., 2013), and three million girls are at risk of undergoing the procedure every year (UNICEF, 2005). A few studies have documented a series of negative psychological effects of the practice including affective and anxiety disorders, chronic depression, post-traumatic stress (PTSD) symptoms, intrusive re-experiences of the FGM procedures, and negative psycho-sexual consequences. However, very few of these studies that are comprehensive and using reliable and valid research methods to explore the complexity of psychological experience of FGM in cultural context. This lecture will discuss results from a WHO study done in Nigeria on the psychological experience of undergoing FGM in the cultural context of a rite of passage.
The Multinational Team in Healthcare – Oyedeji Ayonrinde
While clinical workforces in some countries are becoming increasingly culturallydiverse, marginalized communities remain under-resourced. Dynamic geopolitical, demographic and migration trends produce a shifting and continuous flow of manpower across healthcare systems. The ensuing multinational teams have unique features with the evolution of their own “hybrid†culture. In culturally diverse populations, the interplay between multidisciplinary, multicultural and multinational team factors requires considerable understanding. This presentation highlights the complexities, challenges and potential of multinational healthcare services provided by culturally diverse “healersâ€. Strategic insights are shared from non-medical multinational organizations and their approaches to ensuring value creation and competitive advantage.
Severe mental illnesses: Learnings from diverse contexts and the relevance of a “global†perspective
In 1973, findings from the World Health Organization’s International Pilot Study of Schizophrenia suggested that the outcomes of schizophrenia were better in low- and middle-income countries than in high-income ones. Since then, eloquent arguments have been made for and against this proposition. This session will critically discuss the highlights of this debate and the significant, arguably global developments in services and research focused on severe mental illnesses (e.g., early intervention, a focus on recovery). Much progress has also been made in our understanding of how culture and context influence treatment delays and pathways to care, illness course and outcomes, quality of life, stigma, family involvement, service models and other aspects of severe mental illnesses. Taking a critical perspective, this session will examine the push towards the identification and targeting of global priorities focused on serious mental illnesses and how it may relegate to the margins important, sometimes alternative conceptualizations, frameworks and research.
Knowledge Translation in Global Mental Health – D’souza
Emerging from the Lancet’s (2007) call for action to scale-up services for mental health disorders worldwide, the GMH movement has become a driver of knowledge translation (KT) in the field of mental health. In GMH, KT has been emphasized as key to addressing the treatment gap in LMICs, and in promoting the creation of a global evidence-base. In this session, we will analyze the notions underpinning knowledge translation in GMH, paying close attention to the ways in which global forms of knowledge address specificity, social context and culture. Specifically, we will critically discuss: (i) the forms of evidence that are permitted to contribute to knowledge in GMH; (ii) the tension between ‘scientific’ and ‘embedded/tacit’ knowledge; and (iii) the strategies used to move knowledge between service providers and end users working in complex and under-resourced environments.
The WHO Mental Health Gap Action Program – Laporta & Faregh
In this session we will discuss how the WHO has contributed to raising international awareness of global mental health issues, by offering a global public health perspective: adopting resolutions, setting action plans and targets at the international level, and coordinating programs and responses to the global burden of mental illness. We will briefly review some of the main themes promoted by the WHO, and will then focus more specifically on the mhGAP and its intervention guide, a set of concepts and approaches to mental health problems. We will then briefly describe how work with the mhGAP-Intervention Guide is undertaken in practice, and relate some of our experiences in implementation in different settings . We will highlight some strengths and weaknesses of the approach, and relate some of the literature to our experiences in the necessary adaptations, findings, and recommendations made to the WHO about the mhGAP-IG. This session dedicated to the mhGAP will provide opportunities to discuss several themes related to this Summer Program : (a) the advantages and disadvantages of framing mental health problems as diagnosable disorders having available treatments; (b) whether such diagnoses and treatments of psychiatric disorders are at all generalizable across cultural or social boundaries; (c) the interplay between this ‘model’ and that of a social contextual model of mental health; (d) how do we balance the search for valid approaches to behavioral problems, with contextually driven approaches to coping with mental illness; (e) how do we uphold ethical, respectful practices when working with specific communities. Finally we will discuss actual efforts we are making to develop methodologies to better integrate contextual factors into the mhGAP-IG. Participants will have the opportunity to think through this effort in a brief workshop on this topic integrated into the morning.
Treatment of Depression -Frances Aboud
We will examine how people measure depression, particularly in women, and what we know about the prevalence of depression in LMIC. This will lead into a discussion of public health approaches to reducing maternal depression and its consequences for child health, growth and development.
Primary Health Care and Social Determinants – Anne Andermann
Many of the physical and mental health problems that are dealt with in primary care settings are rooted in underlying social challenges that patients, families and communities face. While frontline health workers are generally aware that these larger contextual issues are important causal factors in the development of illness, they are often unsure how to ask about these issues or what to do when these challenges are disclosed in the clinical setting. However, there is a long tradition of community-oriented primary care (COPC) that blends clinical practice with broader public health action to prevent poor health by taking action more “upstream†to reduce human suffering as well as reducing the burden on clinical services. Since the publication of the WHO Commission report entitled Closing the Gap in a Generation, there has been growing interest in the concrete actions that frontline health care workers can use to address the underlying social determinants of health in clinical practice, at the patient level, at the practice level and at the community level. Barriers and facilitators to adopting such an approach will be discussed with particular emphasis on low- and middle-income country settings, as well as better supporting disadvantaged populations within high incosme countries (e.g. neighborhoods with high rates of poverty, newly arrived immigrants and refugees, Aboriginal communities, etc.).
