"Otherness", otherism, discrimination, and health inequalities: entrenched challenges for modern psychiatric disciplines.

Identity is a complex concept that can be informed by various factors, involving biological, psychological, experiential, and social influences. Specifically, one's social identity refers to the ways in which individuals can adopt attributes from established collective categories, like cultural identities, ethnic identities, gender identities, and class identities, amongst others. Social identity can encompass unique and diverse interactions at an individual level, known as micro-identities, that may be selectively expressed, hidden, or downplayed, contingent on distinct sociocultural settings. However, the formation of social identity is recurrently defined in opposition to perceptions of the Other, which can entail adverse paradigms of marginalisation, stigma, and discrimination. Although this theory of Otherness has been developed across different fields, particularly sociology, it may be important in psychiatric contexts as it can engender inherent risk factors and mental health inequalities. Consequently, this paper seeks to bring attention towards these issues, exploring the construction of Otherness and its detrimental outcomes for psychiatry, such as systemic discrimination and disparities in therapeutic support, alongside recommended initiatives to mitigate against the effects of Otherness. This may require multifactorial approaches that include cultural competency training, interventions informed by micro-identities and intersectionality, patient advocacy, and structural changes to mental health policy.

Global mental health and climate change: A geo-psychiatry perspectiv.

Climate changes affect planet ecosystems, living beings, humans, including their lives, rights, economy, housing, migration, and both physical and mental health. Geo-psychiatry is a new discipline within the field of psychiatry studying the interface between various geo-political factors including geographical, political, economic, commercial and cultural determinants which affect society and psychiatry: it provides a holistic overview on global issues such as climate changes, poverty, public health and accessibility to health care. It identifies geopolitical factors and their effects at the international and national levels, as well as considers the politics of climate changes and poverty within this context. This paper then introduces the Compassion, Assertive Action, Pragmatism, and Evidence Vulnerability Index (CAPE-VI) as a global foreign policy index: CAPE-VI calculates how foreign aid should be prioritised for countries that are at risk or already considered to be fragile. These countries are characterised by various forms of conflict, disadvantaged by extremes of climate change, poverty, human rights abuses, and suffering from internal warfare or terrorism.

'You get looked at like you're failing': A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff.

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. We interviewed 48 healthcare workers from 18 NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Comparison of the psychological health of students at the higher institutes of nursing and health techniques: A Moroccan multicentre study.

BACKGROUND: Mental health is essential to students' academic success as well as their ability to participate fully and meaningfully throughout all aspects of their lives and throughout their lifespan. AIMS: This study aims to determine the psychological health status of Moroccan nursing and technique health students. In doing so, it also seeks to compare differences based on sociodemographic factors. METHOD: A multicenter cross-sectional study with a convenience sample was conducted with 2,054 participants in the academic year of 2018/2019. A set of socio-demographic information were collected, and The General Health Questionnaire-12 (GHQ-12) was used. RESULTS: The mean GHQ-12 score was 4.33 ± 2.61, and 58.7% respondents scored 4 and above in the GHQ-12 scores and thus were considered to be in psychological distress. Students' psychological distress was associated with female gender (60.4% for female compared to 52.4% for men, p = .003); living in parental residence (61.6% compared to 54.7% living away parental residence; p = .02 ), the second and the third training level year respectively (64.6%; 59.2%) compared to first-year (55.2%, p = .001), and midwifery and nursing students (61.6%; 60.3%) as compared to technique health students (43.6%, p = .001). CONCLUSIONS: It appears that a substantial number of students have psychological distress and this is likely to have negative effects on students' educational attainment and wider wellbeing.

Outside/inside: social determinants of mental health.

Individuals' mental health and wellbeing are dependent on many social factors including housing, employment, education and adequate nutrition among others. These factors can influence at personal, family and community levels. The interlinked and cumulative impact of these social determinants needs to be ascertained to aid appropriate patient management, as well as to establish prevention and health education programmes. Some of these determinants also have to be recognised at policy level. It is crucial for clinicians to understand the role social determinants play in the genesis and perpetuation of mental and physical illnesses, so that appropriate social interventions can be set in place. Clinicians have a role to play in their clinical practice, as well as advocates for their patients and policy leaders. In order to ensure that health is joined up with other sectors, such as education, employment, judiciary and housing, policy-makers must avoid silos. Every policy must have an impact assessment on physical health and mental health. Policy-makers need to understand scientific evidence and must work with researchers, clinicians, communities and patients to help develop and implement rights-based policies.

Systematic review and meta-analysis of augmentation and combination treatments for early-stage treatment-resistant depression.

BACKGROUND: Major depressive disorder (MDD) is a highly burdensome health condition, for which there are numerous accepted pharmacological and psychological interventions. Adjunctive treatment (augmentation/combination) is recommended for the ~50% of MDD patients who do not adequately respond to first-line treatment. We aimed to evaluate the current evidence for concomitant approaches for people with early-stage treatment-resistant depression (TRD; defined below). METHODS: We systematically searched Medline and Institute for Scientific Information Web of Science to identify randomised controlled trials of adjunctive treatment of ⩾10 adults with MDD who had not responded to ⩾1 adequate antidepressant. The cochrane risk of bias (RoB) tool was used to assess study quality. Pre-post treatment meta-analyses were performed, allowing for comparison across heterogeneous study designs independent of comparator interventions. RESULTS: In total, 115 trials investigating 48 treatments were synthesised. The mean intervention duration was 9 weeks (range 5 days to 18 months) with most studies assessed to have low (n = 57) or moderate (n = 51) RoB. The highest effect sizes (ESs) were from cognitive behavioural therapy (ES = 1.58, 95% confidence interval (CI): 1.09-2.07), (es)ketamine (ES = 1.48, 95% CI: 1.23-1.73) and risperidone (ES = 1.42, 95% CI: 1.29-1.61). Only aripiprazole and lithium were examined in ⩾10 studies. Pill placebo (ES = 0.89, 95% CI: 0.81-0.98) had a not inconsiderable ES, and only six treatments' 95% CIs did not overlap with pill placebo's (aripiprazole, (es)ketamine, mirtazapine, olanzapine, quetiapine and risperidone). We report marked heterogeneity between studies for almost all analyses. CONCLUSIONS: Our findings support cautious optimism for several augmentation strategies; although considering the high prevalence of TRD, evidence remains inadequate for each treatment option.

Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study.

BACKGROUND: Previous studies on the impact of the COVID-19 pandemic on the mental health of health-care workers have relied on self-reported screening measures to estimate the point prevalence of common mental disorders. Screening measures, which are designed to be sensitive, have low positive predictive value and often overestimate prevalence. We aimed to estimate prevalence of common mental disorders and post-traumatic stress disorder (PTSD) among health-care workers in England using diagnostic interviews. METHODS: We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders. The recruitment period for the diagnostic interviews was between March 1, 2021 and Aug 27, 2021. Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD. FINDINGS: The screening sample contained 23 462 participants: 2079 participants were excluded due to missing values on the GHQ-12 and 11 147 participants due to missing values on the PCL-6. 243 individuals participated in diagnostic interviews for common mental disorders (CIS-R; mean age 42 years [range 21-70]; 185 [76%] women and 58 [24%] men) and 94 individuals participated in diagnostic interviews for PTSD (CAPS-5; mean age 44 years [23-62]; 79 [84%] women and 15 [16%] men). 202 (83%) of 243 individuals in the common mental disorders sample and 83 (88%) of 94 individuals in the PTSD sample were White. GHQ-12 screening caseness for common mental disorders was 52·8% (95% CI 51·7-53·8). Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14·3% (10·4-19·2), population prevalence of depression was 13·7% (10·1-18·3), and combined population prevalence of generalised anxiety disorder and depression was 21·5% (16·9-26·8). PCL-6 screening caseness for PTSD was 25·4% (24·3-26·5). Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7·9% (4·0-15·1). INTERPRETATION: The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention. FUNDING: UK Medical Research Council; UCL/Wellcome; Rosetrees Trust; NHS England and Improvement; Economic and Social Research Council; National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the Maudsley and King's College London (KCL); NIHR Protection Research Unit in Emergency Preparedness and Response at KCL.

Multicentre, England-wide randomised controlled trial of the 'Foundations' smartphone application in improving mental health and well-being in a healthcare worker population.

BACKGROUND: Healthcare workers (HCWs) have faced considerable pressures during the COVID-19 pandemic. For some, this has resulted in mental health distress and disorder. Although interventions have sought to support HCWs, few have been evaluated. AIMS: We aimed to determine the effectiveness of the 'Foundations' application (app) on general (non-psychotic) psychiatric morbidity. METHOD: We conducted a multicentre randomised controlled trial of HCWs at 16 NHS trusts (trial registration number: EudraCT: 2021-001279-18). Participants were randomly assigned to the app or wait-list control group. Measures were assessed at baseline, after 4 and 8 weeks. The primary outcome was general psychiatric morbidity (using the General Health Questionnaire). Secondary outcomes included: well-being; presenteeism; anxiety; depression and insomnia. The primary analysis used mixed-effects multivariable regression, presented as adjusted mean differences (aMD). RESULTS: Between 22 March and 3 June 2021, 1002 participants were randomised (500:502), and 894 (89.2%) followed-up. The sample was predominately women (754/894, 84.3%), with a mean age of 44⋅3 years (interquartile range (IQR) 34-53). Participants randomised to the app had a reduction in psychiatric morbidity symptoms (aMD = -1.39, 95% CI -2.05 to -0.74), improvement in well-being (aMD = 0⋅54, 95% CI 0⋅20 to 0⋅89) and reduction in insomnia (adjusted odds ratio (aOR) = 0⋅36, 95% CI 0⋅21 to 0⋅60). No other significant findings were found, or adverse events reported. CONCLUSIONS: The app had an effect in reducing psychiatric morbidity symptoms in a sample of HCWs. Given it is scalable with no adverse effects, the app may be used as part of an organisation's tiered staff support package. Further evidence is needed on long-term effectiveness and cost-effectiveness.

Capturing the experiences of UK healthcare workers during the COVID-19 pandemic: A structural topic modelling analysis of 7,412 free-text survey responses.

BACKGROUND: Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic. METHODS: In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, "Is there anything else you think we should know about your experiences of the COVID-19 pandemic?". We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts. RESULTS: We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK. DISCUSSION: Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research.

International medical graduates: challenges and solutions in psychiatry.

International medical graduates provide a valuable service to the healthcare of their adopted countries. However, there remain a significant number of challenges in their adjustment and acculturation in the post-migration phase. We believe that the cultural capital these doctors bring with them can act as a support as well as a challenge. They are likely to face subtle and not-so-subtle, covert and overt discrimination at a number of levels. In this brief report, we highlight some of the issues faced by them and some potential solutions.

Prevalence of burnout in medical students in Guatemala: Before and during Covid-19 pandemic comparison.

Burnout is a syndrome consisting of physical, emotional, and mental exhaustion along with depersonalization and poor sense of personal accomplishment. Often related to work conditions. Several recent studies from around the world have shown high rates of burnout among medical students in different countries. In Guatemala City, we decided to assess levels of burnout in 2017 and then again in December 2020. In the first wave from one private medical school, we had a total of 159 respondents (response rate of 56.7%) and 132 (48.5%) in the second wave. Not surprisingly rates of burnout were higher during the pandemic even though response rate is lower. Surprisingly we found that rates of depersonalization had not increased, and levels of personal accomplishment had. These findings present a mixed picture of levels of burnout in Guatemala City. Further qualitative research is indicated to explore cultural differences in order to set up appropriate and suitable intervention strategies.

Psychological concerns of Indian women with breast cancer in different national contexts: a systematic review and mixed-methods synthesis.

BACKGROUND: Breast cancer is becoming the most common cancer among women of Indian origin. However, little is known about the psychological impact of the disease and its treatment among this population. AIM: To improve understanding of psychological symptoms among Indian women with breast cancer. DESIGN: This is a systematic literature review and critical interpretive synthesis. Medical Subject Headings(MeSH) terms and keywords for breast cancer, psychological symptoms and treatment were used to search databases from inception to 7 May 2019. The reference lists of the included articles were examined. Search results were screened against the inclusion criteria, data were extracted, and quality was appraised by two independent researchers with recourse to a third. Narrative (quantitative) and thematic qualitative syntheses were applied, followed by critical interpretive synthesis. DATA SOURCES: ProQuest, MEDLINE, Ovid EMBASE, EBSCO, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. RESULTS: 18 of 763 studies from India or Canada were included (13 quantitative, 5 qualitative). Critical interpretive synthesis found psychological concerns similar to 'Western' women, but were framed by the common culture of Indian women in either country. Family structure, religion and community appear to protect against and cause distress in relation to the expected core role of being a wife and a mother and the male dominance in decision making. Stigma was amplified by poor knowledge about the nature of cancer. Migrant Indian women had additional problems due to language barriers. CONCLUSIONS: Indian women with breast cancer living in India and Canada experience psychological morbidities which profoundly affect their role in their family and the wider community. Culturally congruent care, including accessible communication and information, may help prevent and alleviate distressing symptoms whether in India or in a migrant community.

COVID-19 pandemic, mental health care, and the UK.

The unprecedented SARS-2 COVID-19 pandemic has had a profound impact on individuals, families, and societies worldwide. The impact of the illness does not only directly relate to poor health on infection but also social and political determinants of health. As such, the secondary effects of the pandemic have been profound. Mental health and well-being have been one such area of concern, with the causal links thought to occur in three ways. First: the impact on general population, particularly vulnerable groups such as BAME individuals; Second: the impact on people with pre-existing psychiatric disorders; Third: mental health of COVID patients and those who have recovered and their careers. There are lessons to be learnt from previous pandemics and the impact on mental health. There are high levels of anxiety, depression, substance use (particularly alcohol), posttraumatic stress symptoms, and survivor guilt. Within this context, there is a need to consider the differential impact on underprivileged populations. Vulnerable groups include women, children, elderly, minority racial and ethnic groups, LGBT + individuals and the poor. It is noted that these classifications are met with challenges related to definition, and there is significant heterogeneity within the groups and the focus on race, gender, and poverty must be seen through an intersectional lens.

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.

OBJECTIVES: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK. METHODS: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale. RESULTS: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse. CONCLUSIONS: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.

Managing COVID-19 related distress in primary care: principles of assessment and management.

COVID-19 will cause normal feelings of worry and stress and many of those who experience higher levels of distress will experience resolution of their symptoms as society returns to pre-COVID-19 functioning. Only a minority are likely to develop a psychiatric disorder. Certain individuals may be vulnerable to experiencing persisting symptoms, such as those with pre-existing comorbidity. Management approaches could centre around using collaborative approaches to provide and build on already existing socioeconomic support structures, the avoidance of over-medicalisation, watchful waiting and finally treating those who do meet the criteria for psychiatric diagnosis. Primary care clinicians are likely be the first healthcare point of contact for most COVID-19 related distress and it is important that they are able to provide evidence based and evidence informed responses, which includes social, psychological and pharmacological approaches. This expert opinion paper serves to summarise some approaches, based primarily on indirect extrapolation of evidence concerning the general management of psychological distress, in the absence of COVID-19 specific evidence, to assist primary care clinicians in their assessment and management of COVID-19 related distress.