Tag Archives: Mental health

Why maternal mental health should be a priority

Post originally appeared here.

As 2015 quickly approaches, the global health community has been made increasingly aware of our progress toward Millennium Development Goals (MDGs). Some remarkable progress has indeed been made. For example, the proportion of underweight children under the age of five in developing countries has declined from 28% to 17%between 1990 and 2011. Significant progress has also been made in reducing mortality among children under the age of five. In 1990, 12 million children under five died, compared with 6.9 million children in 2011. In 2011, 2.5 million people were newly infected with HIV, representing a 24% decrease from the 3.1 million people newly infected in 2001. However, one millennium development goal has shown particularly slow progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal morality by 75%. Sub-Saharan Africa is in the most dire position, with a regional maternal mortality rate of 640 maternal deaths out of 100,000 live births, and a decline rate of merely 0.1%. In the summer of 2012, the University of Cambridge hosted a conference on the topic of “New Approaches to Maternal Mortality,” recognizing the crucial need to address the question of what is going on with global maternal mortality rates and to begin to address potential solutions.

While numerous factors are still converging to produce this grim picture, one key element is often missing from the discussion: improving maternal mental health. Working toward solutions to mental health problems that plague new mothers in a wide variety of settings, including in developing countries, could go a long way in improving both maternal and child health. Integrating mental health programs with maternal health programs is not only as important in saving mothers’ lives as screening for malaria and treating HIV in pregnant women but it could also prove essential in achieving two distinct but interrelated Millennium Development Goals: improving maternal health and reducing the number of deaths in children under the age of 5.

A recent article in PLOS Medicine delineates some reasons why maternal mental health is not a high priority on maternal health agendas. For one thing, a number of myths prevail that make maternal mental health seem irrelevant or unimportant in comparison to other threats facing maternal health. One especially troubling myth is the notion that maternal mental health problems are rare in developing countries, where maternal deaths represent a more significant problem than in the developed world. The authors note that this perception is misguided and cite evidence that rates of perinatal depression in low- and middle-income countries are actually higher than in high-income countries, ranging from 18% to 25%. Another misperception involves the idea that maternal depression is only tangential to maternal health. There is a conception that obstetric complications and infectious diseases represent much more immediate threats to maternal health than mental health issues. Yet this notion turns out not to be entirely true. Maternal depression certainly contributes in a very direct and striking manner to poor outcomes in infants. Maternal depression has been associated with pre-term birth, low birthweight, undernutrition, and higher rates of diarrheal disease. Suicide is actually a leading contributor to maternal mortality worldwide, and suicidal thoughts and tendencies occur in up to 20% of mothers in low- and middle-income mothers, in comparison with 5 to 14% of mothers in high-income countries.

Part of the problem with treating maternal depression is that it can be difficult to detect, especially in resource-poor countries. Core symptoms of depression such as fatigue and poor sleep are also effects of motherhood and often go unnoticed in new mothers. Screening for depression should be an integral component of antenatal visits and health care professionals who do not specialize in mental health should be trained to recognize symptoms of depression in pregnant women and new mothers. Over the last decade, interventions by non-mental health specialists have produced promising results, and efforts are being expanded to low- and middle-income countries with encouraging outcomes. ThePerinatal Mental Health Project (PHMP), based at the Mowbray Maternity Hospital in South Africa, included screening by midwives of all women in antenatal care for mental health problems and referrals for counseling and psychiatric care if necessary. The intervention resulted in high coverage (90%) and uptake (95%) of PMHP screening, and staff responsible for the screening expressed relief, rather than a feeling of burden, about the integration of maternal and mental health systems in order to address a previously unmet need.

International donors and stakeholders should be made aware of the dire effects of maternal depression on maternal and child health and should be encouraged to provide funds and aid specifically for maternal mental health. In particular, the evidence for the effects of mental health on physical health should be emphasized in communication with international donors. In addition, donors should be made aware that integrating mental health services into existing treatment platforms could prove an important opportunity to leverage resources efficiently, a major current preoccupation of the global health community.

If the Millennium Development Goals are to be achieved, the international health community needs to stop viewing them in isolation from each other and recognize that many of them are intertwined and require integrated interventions. At the same time, holistic views of both health systems and individual health are vital. Strengthening across health systems, which includes strengthening local mental health services, will bring us closer to achieving the MDGs. In a similar manner, viewing individual health holistically, as the combined effect of the health of various systems, including not only the body but also the mind, will help ensure that we pay due attention to a wider variety of factors contributing to poor health worldwide.

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Why Mental Illness-Focused Gun Control May Be More Harmful Than Helpful

This article was originally published here.

Dr. Sara Gorman examines the risks involved with mental illness-focused gun control.

In the aftermath of the mass shooting earlier this year in Newtown, Connecticut, debates have been raging in the U.S. about what steps to take to prevent such tragedies in the future. In particular, policy officials and the public alike have been pondering whether more stringent controls on potential gun buyers and gun owners with mental illness should be implemented and what these controls might look like. Shortly after the Newtown shootings, Senator elect Marco Rubio called for guns to be “kept out of the hands of the mentally ill.” In a more extreme statement, the National Rifle Association (NRA) suggested an “active national database of the mentally ill.” A recent study by researchers at the John Hopkins Bloomberg School of Public Health found striking similarities in the opinions of gun-owners and non-gun-owners when it came to restricting the ability of people with mental illness to own guns. 85% of all respondents to the survey supported requiring states to report people to national background-check systems who are prohibited from owning guns because of a history of being involuntarily committed or being declared mentally incompetent by a court. Most respondents, whether gun-owners or non-gun-owners, were resistant to allowing people with mental illness to own guns. Clearly, the provision of tight restrictions on potential gun owners with mental illness is an unusual arena in which gun-owners and non-gun-owners can agree.

There is no question that guns pose a potentially serious problem for people with mental illness. Some forms of mental illness can be associated with heightened potential for violence, but, more importantly, the risk for successful suicide among depressed persons with guns is much higher than the risk for those without guns. Nevertheless, are gun control efforts that require the names of people with mental illness to be kept in a national database such a good idea?

The truth is, we have to be much more careful about gun control efforts that have the potential to target people with mental illness. There are two main reasons to approach these kinds of laws with a healthy dose of caution: one reason is that gun control efforts focusing on mental illness have the potential to exacerbate public stigma about the potential violence associated with mental disorders; the second reason is that gun laws that in particular involve collecting the names of people with mental illness in national databases have the potential to deter people from seeking the care they may desperately need.

Ample evidence has suggested that stigma and discrimination against people with mental illness is often correlated with perceptions that people with mental illness are inherently violent. People who believe that mental illness is associated with violence are more likely to condone forced legal action and coerced treatment of people with mental illness and may feel that victimizing and bullying people with mental illness is in some way justified. The idea that mental illness and violence are closely related is quite common. A 2006 national survey found that 60% of Americans believed that people with schizophrenia were likely to act violently toward another individual. Even so, research has repeatedly established that psychiatric disorders do not make people more likely to act in a violent manner. Gun laws targeting people with mental illness are likely to worsen the perception that mental illness and violence go hand in hand, and, as a result, stigma and discrimination are likely to be exacerbated.

Gun laws targeting people with mental illness may in some instances save lives. Successful suicides, or even suicide attempts, might be avoided, for instance. On the other hand, in addition to perpetuating a stigmatizing belief that people with mental illness are dangerous, gun laws that focus on people with mental illness might involve measures that deter people from seeking psychiatric care. If people are afraid that the government and other parties will have access to their confidential mental health information, they may be much more reluctant to seek help in the first place. In the end, this kind of deterrence could cause more harm than good, not to mention that increased stigma and discrimination also often lead to a decrease in help-seeking behaviors.

It is true that the U.S. mental health system is in need of reform and that strategies to detect people in danger of hurting themselves or others earlier are desperately needed. Even so, it is difficult even for mental health professionals to predict the future violence potential of their patients. Furthermore, it is not only misguided but also potentially harmful to focus gun control efforts on people with psychiatric disorders. What’s more, these kinds of efforts will probably make very little difference in the homicide rate in the U.S. It would be more worth our while to focus gun control efforts not on mental illness per se but perhaps more importantly on alcohol abuse. The association between alcohol abuse and gun violence is convincing. As a result, in Pennsylvania, for example, people who have been convicted of more than three drunk driving offenses may not purchase a gun. Keeping guns out of bars and other drinking establishments is also probably a wise move. Doing background checks for domestic violence is also a useful measure in reducing gun violence in the home. As the U.S. reconsiders gun control legislation, it is important to recognize that some measures might do more harm than good. Paying closer attention to scientific evidence and remaining focused on the most effective strategies for targeting those most likely to commit violent acts must be the strategy going forward.

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The importance of improving mental health research in developing countries

Originally published at The Pump Handle

In response to the realization that between 16% and 49% of people in the world have psychiatric and neurological disorders and that most of these individuals live in low- and middle-income countries, the World Health Organization (WHO) launched the Mental Health Gap Action Programme to provide services for priority mental health disorders in 2008. This focus on services is essential, but the WHO ran into a significant problem when confronting mental health disorders in the developing world: lack of research made it difficult to understand which mental health disorders should be prioritized and how best to reach individuals in need of care.

In 2011, The World Health Organization (WHO) embarked on a report entitled “No health without research.” The release of the report was recently postponed, but the problem identified by the report remains no less dire. In order to improve health systems in low- and middle-income countries, support for more research in epidemiology, healthcare policy, and healthcare delivery within these countries is essential.

Over the course of the past year and a half, PLoS Medicine has published a series of papers corresponding with this theme. In one paper, M. Taghi Yasamy and colleagues emphasize the importance of scaling up resources for mental health research in particular. This research, they explain, will help policymakers determine directions for improving policy and delivery of mental healthcare. Advancing this research will be challenging, though, because good governance for mental health research in developing countries is lacking.

Some of the most immediate problems with mental health research in developing countries are financial. Most developing countries lack institutions like the National Institute of Mental Health (NIMH) to help fund and structure research. Physicians and mental health professionals often have no incentive to conduct research because providing other health services is much more lucrative. In some cases, as in many countries in Latin America, researchers must fund their own research and experience no financial gain as a result of conducting research.

Yet financial reasons are not the only reasons for lack of mental health research in developing countries. Restructuring medical education could go a long way toward preparing physicians to participate in research. While research is valued as a key part of medical education and success in the United States, research is not a determining factor for getting into residency or achieving academic success in low-income countries. Many physicians-in-training thus encounter a lack of incentive to contribute to research initiatives. Making research a fundamental part of success in medical training could help make universities in low- and middle-income countries the research centers they are in high-income countries.

Even when clinicians and scientists in low- and middle-income countries are able to conduct mental health research, they often find it difficult to publish their findings in prestigious, widely circulating international medical journals. Researchers from developing countries often struggle to meet the requirements of indexed journals because of lack of access to information, lack of guidance in research design and statistical analysis, and difficulty communicating in foreign languages. Researchers in developing countries often work in research centers or universities that are not considered “prestigious” on an international scale and may not garner the attention of international journals. Editors may be more likely to give serious consideration to submissions from authors at big-name universities. Another serious problem with publication of research from developing countries in prestigious medical and scientific journals is the language barrier, with most top journals being English-language. Procuring better translation services for scientists in developing countries could be key in overcoming the dearth of publications from these areas of the world.

Policymakers and providers in developing countries may also struggle to learn about findings published in expensive journals for which their institutions cannot afford subscriptions. Open access policies represent one way to alleviate some of the problems mental health researchers in developing countries confront. Free access to a wider body of research published in highly-regarded journals could vastly improve mental health research in developing countries and help researchers attract the attention of these high-level journals.

Mental health interventions that truly help communities in low- and middle-income countries cannot succeed if data on epidemiology of mental disorders, current problems in the delivery of healthcare services, and evidence-based solutions are not available. A survey of mental health research priorities in low- and middle-income countries in 2009 found that stakeholders and researchers ranked three types of research as most important: epidemiological studies of burden and risk factors, health systems research, and social sciences research. Researchers and stakeholders agreed that attending to the growing problems of depression, anxiety, and substance abuse disorders, among other frequently occurring mental disorders, was dependent on procuring better resources for research.

Improving service gaps in mental healthcare is vital, especially in light of a growing epidemic of mental illness globally. But this work cannot be done without more research to identify the problems and evidence-based solutions that will help bring mental healthcare to all those in need.

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Culturally Sensitive Psychiatric Care for Refugees: A Reassessment

Originally published at Health and Human Rights

In recent years, a welcome increase in attention to specific psychological problems among refugees has led to important new insights. Some of this research interest stems from experience with troops and veterans of the Iraqi and Afghani wars. New research has focused not only on the psychiatric effects of torture and human rights abuses, but also on the mental health consequences of victims’ subsequent forced migration. These consequences include the process of seeking asylum, isolation in a new country, and guilt and concern about leaving one’s native land.1, 2, 6

With a renewed focus on the special psychiatric needs of the refugee community, several essential areas of new research have emerged. The epidemiological research on the effects of torture and forced migration on refugee populations has proven helpful in identifying the burden of chronic mental illness on asylum seekers. But are refugees really getting the mental health care they need? Evidence from the Mental Health Commission of Canada suggests that there is a major gap between need and treatment. The report demonstrates that some of the reasons for this inadequacy are related to lack of awareness of available services and socioeconomic barriers. Yet refugees also frequently cite perceived stigma and discrimination as a major barrier to care. This discrimination may not come directly from mental health providers but may be a perceived effect of a system that ignores their special needs. The system inevitably offers poorer treatment options to persons of different cultural backgrounds, including refugees, who may feel cultural barriers particularly prominently as a result of rapid resettlement.

It is quickly becoming apparent that in order to help refugees access treatment and use it successfully, mental health care modules must be adapted to the cultural diversity of the refugee client population.3, 4 Only approaches that incorporate recognition of such diversity have the potential to overcome the low rate of help-seeking behavior among refugees and the often inadequate quality of mental health care they receive.

The language barrier is an urgent problem. Feeling misunderstood by a health care provider is a major barrier to health-seeking behaviors among refugee populations. It may end up unjustly excluding refugees from obtaining treatment. The language barrier between patient and physician causes complex problems. In the case of refugee mental health care, there is the added complication of cultural differences that inform terms for sadness, depression, anxiety, and even psychosis. Semantic equivalency can be achieved in some cases, but it may require extensive consultation with health care workers in the native country who are familiar with the illnesses and words used to describe them.

There is also the question of whether diagnostic questions proposed by the DSM-IV, and its successor, the DSM-V, are phrased in a way that is meaningful in all languages and cultures. For example, in the Somali language, what Western medicine calls PTSD is associated with a form of madness termed waali, basically meaning “madness from trauma.”5 No such sense of “madness” is conveyed by the DSM-IV diagnostic markers for PTSD, which emphasize feelings of anxiety and sadness. The result is that refugees from Somalia may have profound PTSD but may not associate it with the version of the illness presented by the DSM-IV and DSM-V. Quests for semantic equivalency should not only take into account whether a word is translated correctly, but also whether the same concept of the illness exists in the other culture. Translations of diagnostic questions should therefore be culturally, as well as linguistically, informed.

Refugees are needlessly being excluded from the mental health care they desperately need and to which they are entitled. In many cases, this exclusion is the result of unintentional misunderstanding on the part of clinicians. More research should be conducted into how accurately Western notions of PTSD, depression, and other mental illnesses translate across cultures, and how well treatments traditionally used in Western countries for these illnesses work in widespread cultural settings. Most importantly, mental health providers should always remain aware of cultural differences in order to provide the most sensitive, effective, and appropriate care to a population in great need.

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