RESUMO
The pandemic dramatized the close links among cognitive, mental, and social health; a change in one reflects others. This realization offers the opportunity to bridge the artificial separation of brain and mental health, as brain disorders have behavioral consequences and behavioral disorders affect the brain. The leading causes of mortality and disability, namely stroke, heart disease, and dementia, share the same risk and protective factors. It is emerging that bipolar disorders, obsessive compulsive disorders, and some depressions share these risk factors, allowing their joint prevention through a holistic life span approach. We need to learn to focus on the whole patient, not simply on a dysfunctional organ or behavior to mitigate or prevent the major neurological and mental disorders by fostering an integrated approach to brain and mental health and addressing the common, treatable risk factors.
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Transtornos Mentais , Acidente Vascular Cerebral , Humanos , Saúde Mental , Transtornos Mentais/epidemiologia , Encéfalo , Acidente Vascular Cerebral/complicações , Fatores de RiscoRESUMO
While some early studies suggested that spirit mediums were psychiatrically ill individuals who found a culturally sanctioned role, subsequent work has found that they are generally in good physical and mental health. While the calling to be a healer often involves an initiatory illness, practitioners go on to play demanding social roles, suggesting that involvement in mediumship may be therapeutic for the practitioner. This study focuses on dang-ki healing, a form of Chinese spirit mediumship practiced in Singapore to explore whether participation in dang-ki healing is therapeutic for the mediums. We interviewed eight dang-kis from five temples about their life trajectories and assessed their mental health status with standardized psychological questionnaires. Most of the dang-kis did not appear to suffer from clinically significant emotional distress. Their narratives suggest that involvement in dang-ki mediumship may have therapeutic effects in which the embodied experience of self plays a central role. The dang-kis experienced changes in social identity, bodily experiences during spirit possession, and their overall sense of self through recurrent possession rituals. In general, the practice of spirit mediumship illustrates how the experiences and meanings of the self are constructed and reconstructed through body-world relations in ways that may confer a sense of wellness and social efficacy.
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Saúde Mental , Possessão Espiritual , Humanos , Singapura , Ansiedade , EmoçõesRESUMO
Gender differences in the prevalence of psychiatric disorders, with higher prevalence of mood and anxiety disorders among women, have been the focus of much debate. In Iran, the adoption of the construct of Bipolar Spectrum Disorder (BSD) and of the concept of "soft bipolarity" has been associated with a large gender difference in rates of diagnosis. This paper discusses the gendered meanings of the diagnosis of BSD in Iran. In this qualitative study, we conducted 25 in-depth semi-structured interviews with prominent psychiatrists and university professors (7 female and 18 male) at six different universities in Iran and 37 in-depth semi-structured interviews with patients (23 female and 14 male, 18-55 years of age) who had received bipolar spectrum disorder diagnosis and treatment, excluding Bipolar I. Findings suggest that the high rate of diagnosis of bipolar spectrum disorder (i.e., subthreshold or soft bipolar disorder) among women in Iran is influenced by gender, sociocultural, political, and economic factors, as well as the diagnostic practices of biomedical psychiatry. The dominant biological psychiatry system in Iran has led many psychiatrists to frame sociopolitically and culturally rooted forms of distress in terms of biomedical categories like soft bipolarity and to limit their interventions to medication. This bioreductionist approach silences the voices of vulnerable groups, including those of women, and marginalizes discussions of problematic institutional and social power. To understand the preference for biomedical explanations, we need to consider not only the economic interests at play in the remaking of human identity in terms of biological being and the globalization of biological psychiatry, but also the resistance to addressing the sociocultural, political, and economic determinants of women's mental suffering in particular contexts.
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Transtorno Bipolar , Psiquiatria , Feminino , Humanos , Masculino , Transtorno Bipolar/terapia , Transtorno Bipolar/diagnóstico , Irã (Geográfico) , Afeto , Transtornos de AnsiedadeRESUMO
BACKGROUND: Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country. METHODS: Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks. RESULTS: An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (ß1 = - 4.83, 95% CI = [- 5.66, - 4.01], p < .001), whereby both groups improved, with Cohen's effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of 2.82 (95% CI = [1.98, 3.66]) for RT after 7 weeks, suggesting treatment effectiveness for both groups in a real-world setting. Three and six-month follow-up yielded further significant improvement in both groups, which did not differ from each other. CONCLUSION: RT also displayed promising efficiency, considering that it had been discontinued weeks earlier while the paroxetine treatment was continued, as recommended. RT could be taught in low-income countries as part of the local therapeutic resources to treat the core symptoms of PTSD, provided that such results are replicated on a broader scale. TRIAL REGISTRATION: ISRCTN34308454 (11/10/2017).
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Paroxetina , Transtornos de Estresse Pós-Traumáticos , Adulto , Humanos , Nepal , Paroxetina/uso terapêutico , Pobreza , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Resultado do TratamentoRESUMO
This position paper has been substantially revised by the Canadian Psychiatric Association (CPA)'s Section on Transcultural Psychiatry and the Standing Committee on Education and approved for republication by the CPA's Board of Directors on February 8, 2019. The original position paper1 was first approved by the CPA Board on September 28, 2011.
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Etnopsicologia , Internato e Residência , Canadá , Humanos , Sociedades MédicasRESUMO
The Truth and Reconciliation Commission of Canada made it clear that understanding the historical, social, cultural, and political landscape that shapes the relationships between Indigenous peoples and social institutions, including the health care system, is crucial to achieving social justice. How to translate this recognition into more equitable health policy and practice remains a challenge. In particular, there is limited understanding of ways to respond to situations in which conventional practices mandated by the state and regulated by its legal apparatus come into direct conflict with the values and autonomy of Indigenous individuals, communities, and nations. In this paper, we consider two cases of conflict between Indigenous and biomedical perspectives to clarify some of the competing values. We argue for the importance of person- and people-centered approaches to health care. These value conflicts must be understood at multiple levels to clarify their personal, social, cultural, and political dimensions. Taking into account the divergence between epistemic cultures and communities allows us to understand the multiple narratives deployed in decision-making processes in clinical, community, and juridical contexts. Recognizing the knowledge claims of Indigenous peoples in health care can help clinicians avoid reinforcing the divides created by the structural and institutional legacy of colonialism. This analysis also provides ways to adjudicate conflicts in health care decision-making by disentangling cultural, political, medical, and pragmatic issues to allow for respectful dialogue. Insofar as the engagement with cultural pluralism in health care rights is conducted with reciprocal recognition, the medical community and Indigenous peoples can address together the difficult question of how to integrate different epistemic cultures in the health care system.
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Diversidade Cultural , Povos Indígenas , Canadá , Tomada de Decisão Clínica , Colonialismo , Atenção à Saúde , HumanosRESUMO
In recent years, psychiatry in Iran witnessed a dramatic increase in the use of the diagnosis of bipolar spectrum disorder (BSD). This qualitative study maps the journey of the BSD diagnosis from the West to Iran, examines the controversy surrounding the diagnosis and its treatment, and explores some of the structural factors that facilitate and maintain the widespread use of the BSD diagnosis in Iran and related practices of prescribing neuroleptic and mood stabilizers. The study methods include archival research and semi-structured interviews with 25 prominent Iranian psychiatrists in the field of mood disorders. Results show the importance of factors in addition to economics in driving changes in diagnostic fashion. Most psychiatrists interviewed reported what they viewed as an over-diagnosis of bipolar disorder and over-prescription of mood stabilizers and atypical antipsychotics among Iranian psychiatrists over the past decade. In addition to the influence of leading figures of American psychiatry, the dominance of Western psychiatric classifications and textbooks in Iran's psychiatry, and indirect intervention by pharmaceutical companies, local structural and political factors have played a significant role in the Iranian psychiatric system's embrace of the new concept of bipolarity. In Iran, the medicalization of social conflict has been embraced by government, families, and psychiatrists for cross-cutting purposes. These challenges and the continued controversy over the adoption of American psychiatric fads in a non-Western country like Iran point to the importance of elaborating a more ecosocial and cultural view of psychiatric practice to disentangle some of the complex trade-offs involved in adopting particular modes of diagnostic practice.
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Psiquiatria Biológica , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/terapia , Internacionalidade , Antipsicóticos/efeitos adversos , Humanos , Irã (Geográfico) , Medicalização , Estados UnidosRESUMO
Cultural diversity poses a challenge to mental Health care systems in many settings. Specialized cultural consultation services have been developed in a number of countries as a way to supplement existing services. The objective of this paper is to compare and contrast cultural consultation services in Montreal, London, and Paris to determine how culture and society have shaped the evolution of these services to meet local sensitivities and imperatives. Historical contexts of the sites, their descriptions and origins, how they categorize cultural, ethnic, and linguistic diversity, and their intake procedures are compared and contrasted according to a standardized template of themes. Data came from site visits and participant observation at each site. For historical, political, and cultural reasons, categorization of diversity and intake procedures differ markedly by site: Montreal focuses on language categories and language proficiency; London enumerates ethnic diversity according to officially mandated categories; and Paris does not gather ethnic data on its patients in any form. The process of cultural consultation, specifically its triage and intake procedures, is profoundly influenced by local histories and social norms that are maintained by professional cultures of psychiatry in each setting. To properly place their patients in context, cultural psychiatrists must not only aim to understand the culture of the other, but also must consider the culture of the mainstream society and how it shapes the delivery of services.
Assuntos
Diversidade Cultural , Transtornos Mentais/etnologia , Transtornos Mentais/terapia , Serviços de Saúde Mental/organização & administração , Encaminhamento e Consulta , Comparação Transcultural , Feminino , Humanos , Idioma , Londres , Masculino , Serviços de Saúde Mental/normas , Modelos Organizacionais , Paris , QuebequeRESUMO
The target article "Thinking Through Other Minds" (TTOM) offered an account of the distinctively human capacity to acquire cultural knowledge, norms, and practices. To this end, we leveraged recent ideas from theoretical neurobiology to understand the human mind in social and cultural contexts. Our aim was both synthetic - building an integrative model adequate to account for key features of cultural learning and adaptation; and prescriptive - showing how the tools developed to explain brain dynamics can be applied to the emergence of social and cultural ecologies of mind. In this reply to commentators, we address key issues, including: (1) refining the concept of culture to show how TTOM and the free-energy principle (FEP) can capture essential elements of human adaptation and functioning; (2) addressing cognition as an embodied, enactive, affective process involving cultural affordances; (3) clarifying the significance of the FEP formalism related to entropy minimization, Bayesian inference, Markov blankets, and enactivist views; (4) developing empirical tests and applications of the TTOM model; (5) incorporating cultural diversity and context at the level of intra-cultural variation, individual differences, and the transition to digital niches; and (6) considering some implications for psychiatry. The commentators' critiques and suggestions point to useful refinements and applications of the model. In ongoing collaborations, we are exploring how to augment the theory with affective valence, take into account individual differences and historicity, and apply the model to specific domains including epistemic bias.
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Encéfalo , Cognição , Teorema de Bayes , Humanos , Modelos Psicológicos , Comportamento SocialRESUMO
BACKGROUND: Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression. AIM: To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression. METHOD: Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme - Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6). RESULTS: There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI -4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar. CONCLUSIONS: Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care. DECLARATION OF INTERESTS: None.
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Depressão/terapia , Cuidado Pós-Natal , Complicações na Gravidez/psicologia , Complicações na Gravidez/terapia , Cuidado Pré-Natal , Atenção Primária à Saúde , Adulto , Análise por Conglomerados , Análise Custo-Benefício , Feminino , Humanos , Análise Multivariada , Nigéria , Gravidez , Escalas de Graduação Psiquiátrica , Análise de Regressão , Adulto JovemRESUMO
In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.
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Comportamento do Adolescente/psicologia , Transtornos Dissociativos/diagnóstico , Transtornos Dissociativos/psicologia , Modelos Psicológicos , Adolescente , Criança , Estudos Transversais , Transtornos Dissociativos/epidemiologia , Feminino , Humanos , Masculino , Nepal/epidemiologia , Valor Preditivo dos TestesRESUMO
Efforts to provide culturally appropriate global mental health interventions have included attention to local idioms of distress. This article critically examines the potential gap between lay ethnopsychological understandings of the Cambodian idiom of baksbat (broken courage) on the one hand and clinical conceptualizations of the idiom as a potential indicator of posttraumatic stress disorder. Ethnographic semi-structured interviews with trauma survivors reveal resistance to current clinical translations and hybrid Euro-Western and Khmer treatment interventions. While the notion of idioms of distress is intended to draw attention to everyday non-pathologizing forms of discourse, the creation of hybrid assessment and treatment constructs linking idioms to trauma-related pathology may obscure the pragmatic communicative functions of the idiom, making them subordinate to an existing model of psychiatric disorder and pathologizing everyday modes of coping. Participants' narratives highlight self-perceived connections between stressors that determine the trajectory and outcome of distress and shared cultural worldviews that together uniquely shape their meaning. These observations point to the dilemmas of linking idioms of distress with co-morbid illness constructs in ways that may pathologize normal emotional responses. Results have implications for efforts to develop effective models of post-conflict trauma care in global mental health.
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Coragem , Trauma Psicológico/etnologia , Transtornos de Estresse Pós-Traumáticos/etnologia , Terminologia como Assunto , Adulto , Camboja/etnologia , Comorbidade , Etnopsicologia , Feminino , Saúde Global , Humanos , Masculino , Saúde Mental , Trauma Psicológico/diagnóstico , Trauma Psicológico/terapia , Pesquisa Qualitativa , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapia , SobreviventesRESUMO
The processes underwriting the acquisition of culture remain unclear. How are shared habits, norms, and expectations learned and maintained with precision and reliability across large-scale sociocultural ensembles? Is there a unifying account of the mechanisms involved in the acquisition of culture? Notions such as "shared expectations," the "selective patterning of attention and behaviour," "cultural evolution," "cultural inheritance," and "implicit learning" are the main candidates to underpin a unifying account of cognition and the acquisition of culture; however, their interactions require greater specification and clarification. In this article, we integrate these candidates using the variational (free-energy) approach to human cognition and culture in theoretical neuroscience. We describe the construction by humans of social niches that afford epistemic resources called cultural affordances. We argue that human agents learn the shared habits, norms, and expectations of their culture through immersive participation in patterned cultural practices that selectively pattern attention and behaviour. We call this process "thinking through other minds" (TTOM) - in effect, the process of inferring other agents' expectations about the world and how to behave in social context. We argue that for humans, information from and about other people's expectations constitutes the primary domain of statistical regularities that humans leverage to predict and organize behaviour. The integrative model we offer has implications that can advance theories of cognition, enculturation, adaptation, and psychopathology. Crucially, this formal (variational) treatment seeks to resolve key debates in current cognitive science, such as the distinction between internalist and externalist accounts of theory of mind abilities and the more fundamental distinction between dynamical and representational accounts of enactivism.
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Cognição/ética , Cultura , Aprendizado Social/ética , Ciência Cognitiva/tendências , Evolução Cultural , Humanos , Aprendizagem/ética , Neurociências/tendências , Comportamento Social , Normas SociaisRESUMO
In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.
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Princípios Morais , Filosofia Médica , Psiquiatria/ética , Medicina Psicossomática/ética , HumanosRESUMO
A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.
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Acreditação/normas , Competência Clínica/normas , Emigrantes e Imigrantes , Internato e Residência/normas , Médicos/normas , Psiquiatria/normas , Adulto , Diversidade Cultural , Humanos , Médicos/psicologiaRESUMO
BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.
Assuntos
Assistência à Saúde Culturalmente Competente/normas , Manual Diagnóstico e Estatístico de Transtornos Mentais , Entrevista Psicológica/normas , Transtornos Mentais/diagnóstico , Aceitação pelo Paciente de Cuidados de Saúde , Escalas de Graduação Psiquiátrica/normas , Adulto , Estudos de Viabilidade , Feminino , Humanos , Masculino , Transtornos Mentais/etnologia , Pessoa de Meia-IdadeRESUMO
Theories of healing have attempted to identify general mechanisms that may work across different modalities. These include altering expectations, remoralization, and instilling hope. In this paper, we argue that many forms of healing and psychotherapy may work by inducing positive psychological states marked by flexibility or an enhanced ability to shift cognitive sets. Healing practices may induce these states of cognitive and emotional flexibility through specific symbolic interventions we term "flexibility primers" that can include images, metaphors, music, and other media. The flexibility hypothesis suggests that cognitive and emotional flexibility is represented, elicited, and enacted through multiple modalities in healing rituals. Identifying psychological processes and cultural forms that evoke and support cognitive and emotional flexibility provides a way to understand the cultural specificity and potential efficacy of particular healing practices and can guide the design of interventions that promote resilience and well-being.