Addressing racism: the role of mental health professionals.

Racial discrimination and racism are ubiquitous. These feelings and resulting acts of discrimination contribute to the mental illnesses among those who experience it and face it regularly. Although efforts have been made at international level to develop correct definitions and actions to mitigate and eliminate these acts in policies, reality remains very different. Racism is pervasive and can manifest in several, often-overlapping forms as it may be personal, internalised or institutional. The concept of personally mediated racism refers to deliberate social attitudes and behaviours, to racially prejudiced actions, to discrimination towards others according to their race, or devaluation, or stereotyping for the same reasons. Research has shown that discrimination and perceived discrimination contribute to mental ill health as well as poor physical health and poor wellbeing. Managing issues related to racism requires interventions at multiple levels from individual education and training, institutional responses and policy measures. All of these require appropriate funding.

Accidents and undetermined deaths: re-evaluation of nationwide samples from the Scandinavian countries.

BACKGROUND: National mortality statistics should be comparable between countries that use the World Health Organization's International Classification of Diseases. Distinguishing between manners of death, especially suicides and accidents, is a challenge. Knowledge about accidents is important in prevention of both accidents and suicides. The aim of the present study was to assess the reliability of classifying deaths as accidents and undetermined manner of deaths in the three Scandinavian countries and to compare cross-national differences. METHODS: The cause of death registers in Norway, Sweden and Denmark provided data from 2008 for samples of 600 deaths from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of deaths and 200 as natural deaths. The information given to the eight experts was identical to the information used by the Cause of Death Register. This included death certificates, and if available external post-mortem examinations, forensic autopsy reports and police reports. RESULTS: In total, 69 % (Sweden and Norway) and 78 % (Denmark) of deaths registered in the official mortality statistics as accidents were confirmed by the experts. In the majority of the cases where disagreement was seen, the experts reclassified accidents to undetermined manner of death, in 26, 25 and 19 % of cases, respectively. Few cases were reclassified as suicides or natural deaths. Among the extracted accidents, the experts agreed least with the official mortality statistics concerning drowning and poisoning accidents. They also reported most uncertainty in these categories of accidents. In a second re-evaluation, where more information was made available, the Norwegian psychiatrist and forensic pathologist increased their agreement with the official mortality statistics from 76 to 87 %, and from 85 to 88 %, respectively, regarding the Norwegian and Swedish datasets. Among the extracted undetermined deaths in the Swedish dataset, the two experts reclassified 22 and 51 %, respectively, to accidents. CONCLUSION: There was moderate agreement in reclassification of accidents between the official mortality statistics and the experts. In the majority of cases where there was disagreement, accidents were reclassified as undetermined manner of death, and only a small proportion as suicides.

Stigmatization of psychiatrists and general practitioners: results of an international survey.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17% of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Quality of dementia diagnostic evaluation for ethnic minority patients: a nationwide study.

BACKGROUND/AIMS: Diagnostic evaluation of dementia for ethnic minority patients may be challenging. This study aimed to evaluate the quality of diagnostic evaluation of dementia for patients from ethnic minorities in Denmark. METHODS: The Danish national hospital registers were used to identify patients from the main ethnic minority groups in Denmark, who were diagnosed with dementia in the period 2005-2007. Three raters independently reviewed the patients' medical records. Data were compared to data from a previous similar study in the general Danish population. RESULTS: Fifty-seven medical records were reviewed. An acceptable diagnostic workup was documented in only 23% of the patients. Dementia diagnosis was confirmed in 35%. Significant differences in the quality of the diagnostic evaluation were found between patients from ethnic minorities and the general population. CONCLUSION: There are significant ethnic disparities in the quality of diagnostic evaluations and outcome of dementia in the secondary healthcare sector.

Measuring the stigma of psychiatry and psychiatrists: development of a questionnaire.

The stigma of mental illness is a severe burden for people suffering from mental illness both in private and public life, also affecting their relatives, their close social network, and the mental health care system in terms of disciplines, providers, and institutions. Interventions against the stigma of mental illness employ complementary strategies (e.g., protest, education, and contact) and address different target groups (e.g., school children and teachers, journalists, stakeholders). Within this framework, the World Psychiatric Association has adopted an Action Plan with the goal to improve the image of psychiatry and to reduce potential stigmatizing attitudes toward psychiatry and psychiatrists. To evaluate such interventions, a questionnaire has been developed that assesses opinions and attitudes toward psychiatrists and psychiatry in different samples of medical specialists (psychiatrists and general practitioners). The questionnaire comprises scales about perceived stigma in terms of the perception of societal stereotypes, self-stigma in terms of stereotype agreement, perceived stigma in terms of structural discriminations, discrimination experiences, stigma outcomes, and attitudes toward a second medical discipline. It is available in several languages (Arab, English, German, Japanese, Polish, and Spanish) and can easily be adapted for utilization in other medical specialties.

Register-based studies on migration, ethnicity, and health.

INTRODUCTION: Researchers in Denmark have unique possibilities of register-based research in relation to migration, ethnicity, and health. This review article outlines how these opportunities have been used, so far, by presenting a series of examples. RESEARCH TOPICS: We selected six registers to highlight the process of how migrant study populations have been established and studied in relation to different registers: The Danish Cancer Registry, the Danish Central Psychiatric Research Register, the Danish National Patient Register, the Danish National Health Service Register, the Danish Injury Register, and the Danish Medical Birth Register. CONCLUSION: Our paper documents the unique opportunities to study migration, ethnicity, and health through Danish national registers. Our examples show that in Denmark ''country of birth'' is the most commonly used measure. It renders information on whether the person is an immigrant or not, and on ethnic background. Data on migration background (i.e. refugee status vs. family reunification, etc.) is more difficult to obtain and therefore less used. It has been debated if ethnicity should be registered upon using health services; however, some consider it discriminatory. Although, we do not register ethnicity in relation to use of health care in Denmark, our possibilities of linkage between population registers and registers on diseases and healthcare utilisation appear to render the same potentials.

Late mental health changes in tortured refugees in multidisciplinary treatment.

The aim of this study was to examine long-term changes in symptoms of post-traumatic stress disorder, depression, anxiety, and in health-related quality of life in traumatized refugees 23 months after admission to multidisciplinary treatment. The study group comprised 45 persons admitted to the Rehabilitation and Research Centre for Torture Victims in 2001 to 2002. Data on background, trauma, present social situation, mental symptoms (Hopkins Symptom Checklist-25, Hamilton Depression Scale, Harvard Trauma Questionnaire), and on health-related quality of life (World Health Organization Quality of Life-Bref) were collected before treatment and after 9 and 23 months. No substantial changes in mental health were observed at the 9-month follow-up, and the minor decrease in some symptoms observed between the 9 and 23 months may reflect regression toward the mean or the natural course of symptoms in this cohort. Thus, no clinically significant improvement was observed, but there is a need for further studies, in particular randomized trials evaluating the efficacy of various health-related and social interventions among severely traumatized refugees.

Global mental health.

Mental disorders contribute significantly to the Global Burden of Disease, as four out of the ten diseases with the highest burden are psychiatric. About 25% of all develop one or more psychiatric and behavioural disorders during their lifetime. Unipolar depression ranges as the leading mental disorder with respect to disability adjusted life years. The major psychiatric disorders like schizophrenia and depression are found in all cultures and result in significant disability. The cost of mental disorders worldwide needs receiving increasing recognition.

Consequences of collective violence with particular focus on the gender perspective--secondary publication.

There is increasing focus on the gender perspective related to the consequences of collective violence. Women run a greater risk of being victims of sexual violence, but few studies have focused on gender differences with respect to physical violence, sexual violations and the impact on health. Further research is needed on these issues as well as on the identification of evidence based interventions.

A proposed new definition of mental health. / Propozycja nowej definicji zdrowia psychicznego.

The authors propose a new approach to the definition of mental health, different than the definition proposed by the World Health Organization, which is established around issues of person's well-being and productivity. It is supposed to reflect the complexity of human life experience.

EPA guidance on cultural competence training.

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Are suicide deaths under-reported? Nationwide re-evaluations of 1800 deaths in Scandinavia.

OBJECTIVE: Valid mortality statistics are important for healthcare planning and research. Suicides and accidents often present a challenge in the classification of the manner of death. The aim of this study was to analyse the reliability of the national suicide statistics by comparing the classification of suicide in the Scandinavian cause of death registers with a reclassification by 8 persons with different medical expertise (psychiatry, forensic pathology and public health) from each of the 3 Scandinavian countries. METHODS: The cause of death registers in Norway, Sweden and Denmark retrieved available information on a sample of 600 deaths in 2008 from each country. 200 were classified in the registers as suicides, 200 as accidents or undetermined and 200 as natural deaths. The reclassification comprised an assessment of the manner and cause of death as well as the level of certainty. RESULTS: In total, 81%, 88% and 90% of deaths registered as suicide in the official mortality statistics were confirmed by experts using the Swedish, Norwegian and Danish data sets, respectively. About 3% of deaths classified as accidents or natural deaths in the cause of death registers were reclassified as suicides. However, after a second reclassification based on additional information, 9% of the natural deaths and accidents were reclassified as suicides in the Norwegian data set, and 21% of the undetermined deaths were reclassified as suicides in the Swedish data set. In total, the levels of certainty of the experts were 87% of suicides in the Norwegian data set, 77% in the Swedish data set and 92% in Danish data set; the uncertainty was highest in poisoning suicides. CONCLUSIONS: A high percentage of reported suicides were confirmed as being suicides. Few accidents and natural deaths were reclassified as suicides. Hence, reclassification did not increase the overall official suicide statistics of the 3 Scandinavian countries.

Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes.

AIM: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. METHOD: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. RESULTS: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. CONCLUSIONS: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

Current research in transcultural psychiatry in the Nordic countries.

This article discusses major themes in recent transcultural psychiatric research in the Nordic countries from 2008 to 2011: (a) epidemiological studies of migration, (b) indigenous populations, and (c) quality of psychiatric care for migrants. Over the past several decades, the populations of the Nordic countries, Denmark, Finland, Norway, and Sweden, which were relatively homogeneous, have become increasingly culturally diverse. Many migrants to Nordic countries have been exposed to extreme stress, such as threats of death and/or torture and other severe social adversities before, during, and after migration, with potential effects on their physical, mental, social, and spiritual health. Growing interest in transcultural issues is reflected in the level of scientific research and clinical activity in the field by Nordic physicians, psychologists, social scientists, demographers, medical anthropologists, as well as other clinicians and policy planners. Research includes work with migrants and indigenous minorities in the Nordic countries, as well as comparisons with mental health in postconflict countries. We conclude by suggesting future directions for transcultural psychiatry research and providing guidelines for the education and training of future clinicians in the Nordic countries.

Gender, human rights and cultural diversity: reflections on a career in transcultural psychiatry.

The three issues of gender equality, human rights and cultural diversity have dominated my organizational commitments, research, and clinical practice in transcultural psychiatry. These issues are intertwined in many ways and have broad implications for transcultural psychiatry. With increasing globalization, psychiatrists in many countries are likely to be treating patients who have migrated from different cultures and who may have been exposed to a variety of traumatic experiences that have a profound impact on their mental health. Of particular concern is the group of torture survivors and the elucidation of their symptom manifestations, as well as effective therapeutic interventions, which clearly show how human rights issues are linked to research and clinical psychiatry. The analyses of how different ethnic groups use psychiatric services, epitomize how important it is to pay attention to gender aspects in the interpretation of the findings and their therapeutic, as well as policy, implications.