A qualitative study about explanatory models of alcohol use disorder among patients and relatives in a Ugandan mental hospital.

BACKGROUND: Alcohol use disorder (AUD) is a major clinical problem in Uganda. Explanatory models (EMs) of illness are important as they have consequences for treatment. Clinicians´ knowledge about patients´ EMs can improve understanding of the latter´s perspectives and adapting treatments. There is a lack of African studies about EMs of AUD. The aim of this study was to explore EMs for AUD among hospitalized patients and their relatives at the alcohol and drug unit (ADU) at Butabika hospital in Uganda. METHODS: An adapted version of the Explanatory Model Interview Catalogue (EMIC) was used for interviews with ten patients and five relatives to investigate how both hospitalized patients with AUD and their relatives understand the disease. Data were analysed for themes with a qualitative content analysis and support of the software program, OpenCode 4.03. RESULTS: Five major themes were identified from the patient interviews: "Context promotes AUD"; "Alcohol is part of culture"; "Spiritual causes of AUD in the community"; "Help through Western medicine and religious sources is preferred" and "Social problems and stigmatization". Six major themes identified from the interviews with relatives were: "Numerous causes of drinking alcohol"; "Devastating consequences of drinking alcohol"; "Exploiting persons with AUD"; "Others' suffering"; "Relatives struggling for help" and "Suggested solutions". CONCLUSIONS: Patients' EMs of AUD included social and spiritual explanations. Alcohol is seen as an important part of the Ugandan culture among both patients and their relatives. The results indicate it is important in clinical contexts to investigate the EMs of the patients and relatives to individually tailor treatment interventions.

Impact on routine psychiatric diagnostic practice from implementing the DSM-5 cultural formulation interview: a pragmatic RCT in Sweden.

BACKGROUND: Culture and social context affect the expression and interpretation of symptoms of distress, raising challenges for transcultural psychiatric diagnostics. This increases the risk that mental disorders among migrants and ethnic minorities are undetected, diagnosed late or misdiagnosed. We investigated whether adding a culturally sensitive tool, the DSM-5 core Cultural Formulation Interview (CFI), to routine diagnostic procedures impacts the psychiatric diagnostic process. METHOD: We compared the outcome of a diagnostic procedure that included the CFI with routine diagnostic procedures used at Swedish psychiatric clinics. New patients (n = 256) admitted to a psychiatric outpatient clinic were randomized to a control (n = 122) or CFI-enhanced diagnostic procedure (n = 134) group. An intention-to-treat analysis was conducted and the prevalence ratio and corresponding 95% confidence intervals (CI) were calculated across arms for depressive and anxiety disorder diagnoses, multiple diagnoses, and delayed diagnosis. RESULTS: The prevalence ratio (PR) of a depressive disorder diagnosis across arms was 1.21 (95% CI = 0.83-1.75), 33.6% of intervention-arm participants vs. 27.9% of controls. The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI = 0.91-2.86). The prevalence ratio of receiving multiple diagnoses was higher for the CFI group among non-native speaking patients, and lower to a statistically significant degree among native Swedish speakers (PR = .39, 95% CI = 0.18-0.82). CONCLUSIONS: The results suggest that the implementation of the DSM-5 CFI in routine psychiatric diagnostic practice may facilitate identification of symptoms of certain psychiatric disorders, like depression, among non-native speaking patients in a migration context. The CFI did not result in a reduction of patients with a non-definite diagnosis. TRIAL REGISTRATION: ISRCTN51527289 , 30/07/2019. The trial was retrospectively registered.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm.

PURPOSE: Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments. METHODS: A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS. RESULTS: Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85). CONCLUSION: Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment.

The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI-i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient-could prove helpful in alleviating patients' suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.

Interventions to increase migrants' care-seeking behaviour for stigmatised conditions: a scoping review.

BACKGROUND: Despite availability of effective treatments, migrants in high-income countries seek care for conditions associated with stigma to a lower extent than the rest of the population. We conducted a scoping review to map the literature on interventions to increase migrants' care-seeking behaviour in high-income countries for stigmatised conditions. Main body of the abstract: We searched 15 electronic databases and journals, hand-searched references and citations, to identify studies on interventions to increase migrants' care-seeking in high-income countries for stigmatised conditions. We applied language restrictions for English and Swedish, and searched the full time period up to 5 July 2019. Our primary outcome of interest was care utilisation. RESULTS: 5447 records were identified in the literature searches. We identified 16 eligible studies, all from North America, that reported interventions to increase migrants' care-seeking behaviour for hepatitis B (n = 1) and mental health (n = 15). Three approaches were identified: health communication (n = 10), support groups (n = 2), and primary care-based approaches (n = 4). There was a general trend towards community-based interventions tailored to individual migrant groups. Significant gaps were identified in the literature, including studies conducted in Europe and studies including men or children. Furthermore, the choice of study designs introduced significant bias that prevented accurate conclusions on intervention effectiveness. CONCLUSION: The available evidence on interventions to increase migrants' in high-income countries care-seeking behaviour for stigmatised conditions is limited in scope and quality. Future research, using reliable study designs, is needed to fill the remaining gaps and to boost the scope and reliability of the evidence.

Cross-cultural training program on mental health care for refugees - a mixed method evaluation.

BACKGROUND: Refugees tend to have a higher risk of mental ill-health and use mental health services less than the native-born population during their first 10 years in Sweden. Intercultural interactions between refugees and mental health professionals have been described as challenging. Cross-cultural training is proposed as one way to improve care for refugees. Evaluations of such training outcomes are sparse. The overall aim of this study was to evaluate Comprehensive Cross-Cultural Training for mental health care professionals in Stockholm, and to assess training outcomes for participants' perceived knowledge regarding mental health and care for newly arrived refugee patients, asylum seekers and undocumented refugees. In addition, we analysed the dimensionality of the pre- and post-training questionnaires used. METHODS: An embedded mixed-method design was applied. We used pre-and post-training questionnaires (n = 248) and conducted six focus group discussions (FGDs) with mental health professionals after training. Quantitative data was analysed by t-tests and factor analysis, qualitative data was analysed using thematic content analysis. RESULTS: Participants experienced gained knowledge and new perspectives in all aspects covered in the training. Training led to participants restructuring their existing knowledge. Those who had reported experience of refugee patients and working with interpreters pre-training in the past month, had higher ratings of perceived knowledge. Post-training, there were no significant changes in perceived knowledge between those with, and those without, experience of refugee patients and working with interpreters. Factor analysis resulted in 3 factors for the pre-training questionnaire, explaining 71% of the covariance, and 4 factors for the post-training questionnaire, explaining 78% of the covariance. Findings from the post-training FGDs, revealed that refugee patients were described as challenging. Also, that training promoted empathy towards refugees and strengthened participants' professional role. CONCLUSIONS: This cross-cultural training contributed to knowledge development and attitude changes. It was valuable regarding care providers' professional role. Additional outcomes of the training were that participants not only gained knowledge about refugee mental health care but also restructured their existing knowledge.

Differences in psychiatric care utilisation among unaccompanied refugee minors, accompanied migrant minors, and Swedish-born minors.

PURPOSE: To better understand underutilisation of psychiatric care among migrant children, we compared utilisation of psychiatric care among unaccompanied refugee minors and accompanied migrant minors, with Swedish-born minors. METHODS: Using a large longitudinal database of linked national registers, we established a retrospective cohort of 1,328,397 people born 1984-1988 comparing minors born in Sweden to 2 Swedish-born parents (95.4%) to minors who had been arriving in Sweden between 2002 and 2011 with a permanent resident permit and were either unaccompanied refugee minors (0.4%), or accompanied migrant minors (4.0%). The outcome measures were different measures of psychiatric care including in- and outpatient care, and prescribed psychotropic medication. RESULT: Compared with the Swedish-born minors the unaccompanied refugee minors had a higher likelihood of utilisation of all psychiatric care except ADHD medication. However, compared with accompanied migrant minors, the Swedish-born minors had a higher likelihood of having utilised psychiatric care. CONCLUSION: Our study shows that during the first years of living in Sweden, there seems to be fewer barriers to psychiatric care for unaccompanied refugee minors compared to the accompanied migrant minors. There are a number of possible reasons for this including stronger ties with the Swedish society.

Traditional Chinese Medicine Explanatory Models of Depressive Disorders: A Qualitative Study.

Traditional Chinese medicine (TCM) is an alternative medical system utilised by many Chinese. However, the knowledge of TCM concepts of depression is limited amongst clinicians with training in Western biomedicine. The purpose of this study was to obtain a better understanding of the conceptualisation of depression from a group of TCM practitioners. Semi-structured interviews in Chinese were carried out with 10 TCM practitioners in Hong Kong. A case description of major depression disorder (MDD) was used as a basis. Interview texts were transcribed, translated and analysed using qualitative content analysis. Most informants identified the case as a depression pattern, a term that lacked clear definition and standardised criteria. The mechanism of disease for MDD symptoms were regarded to be liver-qi dysregulation and an imbalance of yin and yang. The TCM practitioners implemented individualised diagnosis, treatment, and a holistic concept without clear distinction between the mind and the body. This contrasted with the biomedical tradition of separating psychologisation and somatisation. The meanings given to the concept of depression did not correspond with current DSM or ICD definitions, and the TCM normativity can result in variations in explanatory models.

Clinical challenges in cultural psychiatry - searching for meaning, searching for methods†.

BACKGROUND: Mental health services in Sweden are confronted with globalization and refugee migration from conflict- and war-torn countries. AIM: To discuss how clinicians in Sweden can deal with a series of challenges in a changing globalized society, ranging from difficulties of overcoming barriers to help seeking to difficulties of identifying trauma and finding culturally adapted clinical tools. METHOD: Case vignettes are presented to exemplify challenges. Different approaches developed to support clinicians are presented. RESULTS: The concepts of patient centered care and shared decision-making as well as the cultural formulation interview, are recommended to explore the significance of culture and context in psychiatric assessments. Acknowledging relational aspects of care and of paying attention to the patients' social worlds in clinical work is also essential. CONCLUSIONS: The article includes recommendations for training as well as an appeal for the involvement of the wider society in the work to guarantee equitable and high-quality mental health services for some of the most vulnerable patient groups in society.

Assessment and treatment of asylum seekers after a suicide attempt: a comparative study of people registered at mental health services in a Swedish location.

BACKGROUND: Even though asylum seekers are considered vulnerable to mental ill-health, knowledge of their suicidal behaviour is limited. The aim of this study was to improve our understanding of factors that influence the clinical assessment of asylum seekers who have attempted suicide compared to the assessment of non-asylum seekers. METHODS: The study focused on 88 asylum seekers registered for suicide attempts in mental health services 2005-2009, who were matched for age and gender and compared with 88 suicide attempters with Swedish personal identity numbers. The medical records were analysed with a quantitative protocol, focusing on social risk and protective factors, health history, current clinical picture as well as the assessment procedure, diagnostics, patterns of treatment and follow-up in this clinical group. Data was analysed using the chi-square test, Fisher's exact probability test, and the Mann-Whitney U test. RESULTS: As in earlier studies, asylum seekers were more traumatized, had different social risk factors and received different diagnoses than the controls. Asylum seekers were referred to less specialized follow-up after treatment, in spite of their health history and of previous and current clinical pictures indicating a similar or--in the case of the female asylum seekers--more serious mental health condition. Female asylum seekers also received more intense and prolonged in-patient treatment than female controls. Asylum seekers appeared to have social networks more often than the control group. However, there was less documentation of the social context, previous suicidal behaviour, and on suicide in the family and close environment of the asylum-seeking men. Information on suicidal intent was lacking in a majority of both groups. The time relation of the suicide attempt and the asylum process suggested the importance of the asylum decision, as well as the possible role of earlier mental health problems and premigration stress, for the suicidal behaviour. CONCLUSIONS: The groups had different sets of risk factors and clinical pictures. There was a lack of early and thorough exploration of suicide intent for both groups, and of contextual and subjective factors for the asylum seekers. Differences in follow-up indicate unequal access to care.

Approaching the vulnerability of refugees: evaluation of cross-cultural psychiatric training of staff in mental health care and refugee reception in Sweden.

BACKGROUND: This study evaluates the outcomes of cross-cultural mental health training given to professionals in health care and refugee reception in Stockholm, Sweden. METHODS: A mixed method approach, with quantitative data from questionnaires (n = 232) and ten qualitative focus group interviews, was used. RESULTS: After training, the participants reported that the hindering effect of lack of knowledge on their work decreased significantly from 2.81 (SD1.22) before, to 2.29 (SD1.00) (p < 0.001). Focus group interviews contributed to an understanding of this. According to findings from focus group interviews, after training, the participants shifted from emphasising communication barriers towards empathy with refugees with mental ill-health. CONCLUSION: Training resulted in an increased experienced capacity among participants to understand the social vulnerability of newly-arrived refugees with mental distress. However, the lack of collaboration and the structural barriers between the different organisations were not affected.

The Cultural Formulation Interview as a clinical tool in the assessment of eating disorders: a pilot study.

Background: The Cultural Formulation Interview (CFI) in the DSM-5 is a person-centered instrument for systematically appraising the impact of sociocultural factors in psychiatric assessment. The CFI has been shown to be feasible, acceptable, and useful in various clinical contexts. However, to this date there is only one published report describing the use of the CFI with patients with eating disorders. Aims: To explore the potential benefits and challenges of utilizing the CFI in the assessment of eating disorders. Methods: As an addendum to an ongoing qualitative study about barriers to treatment for eating disorders for individuals with a migration background in Sweden, we utilized the CFI in the assessment of adult patients (n=8) in specialist eating disorder treatment. Interview data were analyzed employing a thematic analysis framework. Participants provided feedback using a standard form for evaluation of the CFI. Results: Certain CFI questions proved especially meaningful in this context. In response to the CFI question about patient explanatory models, previously unrecognized ideas about causation emerged. These included perfectionism-a known risk factor for eating disorders-based on immigrant parents' career expectations and experiences of strict family control over life choices. In response to the CFI questions on cultural identity and its impact, the participants provided rich descriptions including important themes such as religion, racism, and ambiguities associated with being a second-generation immigrant. The final CFI question, eliciting concern about the patient-clinician relationship, revealed numerous examples of prejudice and unfamiliarity with migrant groups among healthcare providers. Implications: The CFI can be useful in the assessment of patients with eating disorders and should be further explored as a standard tool in specialist eating disorder services.

"I had no idea there were psychiatric clinics for children": A qualitative study of how migrant parents reach Swedish mental health services for their children.

Migrant children have repeatedly been shown to underutilize psychiatric services and to face barriers to care, yet few studies have examined the experience of migrant parents who are successful in their help-seeking efforts for their children's mental health. The aim of this study was to gain a deeper understanding of facilitators and obstacles to reaching care among migrant parents in contact with child psychiatric services. We explored how migrant parents in Stockholm, Sweden, experienced the process of reaching child mental health services. Participants were recruited from out-patient mental health clinics. Ten in-depth interviews were conducted; qualitative analysis of transcripts was undertaken using thematic content analysis. Parents described a desire to reach services but difficulties doing so on their own. We identified a strong dependence on referring agents, such as schools and child health centers, for parents to gain contact. Informants expressed a high degree of trust toward these agents. Contrary to previous studies, stigma was not described as an obstacle to help-seeking but was recognized by informants as a potential barrier to care had they not emigrated. Although participants in our study had differing educational backgrounds and residency times in Sweden, a common experience of reliance on others for reaching services was evident in the data. Our findings highlight the role of referring agents as bridging contacts between different welfare services. Understanding the specific local resources and services that are available to migrant parents, and strengthening these across different sectors, could potentially help reduce barriers to care.

What information did the DSM-5 Cultural Formulation Interviews provide when used with Swedish-speaking patients in a psychiatric setting in Stockholm?

Introduction: Cultural and contextual factors affect communication and how psychiatric symptoms are presented, therefore psychiatric assessments need to include awareness of the patients' culture and context. The Cultural Formulation Interview (CFI) in DSM-5 is a person-centred tool developed to support the exploration of cultural and contextual factors in an individualized and non-stereotypic way. Methods: The aim of this qualitative study was to find out what information the DSM-5 CFI revealed when used with native Swedish-speaking patients as part of routine clinical psychiatric assessment at an outpatient clinic. An additional aim was to enhance understanding of what kind of information the questions about background and identity yielded. The CFI was added to the psychiatric assessment of 62 native Swedish-speaking patients at an outpatient psychiatric clinic in Stockholm. Results: From the thematic analysis of the documented CFI answers, six central themes were found; Descriptions of distress and dysfunction, Managing problems and distress, Current life conditions affecting the person, Perceived failure in meeting social expectations, Making sense of the problem, and Experiences of, and wishes for, help. The CFI questions about identity yielded much information, mainly related to social position and feelings of social failure. Discussion: For further refinement of the CFI, we see a need for re-framing the questions about cultural identity and its impact on health so that they are better understood. This is needed for majority population patients as direct questions about culture may be difficult to understand when cultural norms are implicit and often unexamined. For clinical implications, our findings suggest that for cultural majority patients the DSM-5 CFI can be a useful person-centred tool for exploring cultural and, in particular, social factors and patients' perception and understanding of distress.

A qualitative analysis of the documentation of DSM-5 Cultural Formulation Interviews with non-native speaking patients in a Swedish mental health care setting.

Introduction: Cultural variety in expressed symptom presentations of mental health problems creates difficulties in transcultural diagnostic assessments. This emphasizes the need of culturally sensitive diagnostic tools like the Cultural Formulation Interview (CFI). Although the CFI is being implemented worldwide there is a lack of studies analyzing what kind of information it provides when used with new patients in routine psychiatric assessments, and how CFI information contributes to diagnostic evaluations. This study aimed to find out what information the CFI questions revealed when used with non-native Swedish speaking patients. We also wanted to understand how the CFI may facilitate identification of psychiatric diagnoses among these patients. Materials and methods: The CFI was used as part of a routine clinical psychiatric assessment in an outpatient clinic in Sweden. Interpreters were used in the consultations when needed. A qualitative thematic analysis was used to analyze the documented CFI answers from non-native speaking patients. Results: We found that the CFI information contained contextualized descriptions of dysfunction and current life conditions, as well as expressions of emotions, often described along with somatic terms. Discussion: Our results indicate that the narrative approach of the CFI, giving contextualized information about distress and functioning, can facilitate clinicians' identification of psychiatric symptoms when language, psychiatric terms and understandings are not shared between patient and clinician.

[Post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) - a clinical update of knowledge]. / Posttraumatiskt stressyndrom (PTSD) och komplex PTSD (CPTSD).

Post-traumatic stress disorder, PTSD, is a psychiatric diagnosis that describes a condition where one or more very traumatic events, that include life-threatening or extreme psychological stress, have left permanent traces of distress that induce sustained suffering.  In this clinical overview, we present current updates in diagnostic criteria and a new diagnosis of complex PTSD, and discuss the problems caused by the new PTSD diagnosis criteria partially differing in the DSM-5 and ICD-11 diagnostic manuals. Diagnostic challenges caused by symptom variations is discussed, as well as the high degree of comorbidity with other psychiatric and somatic illnesses. Combined forms of treatment that reduce both psychological PTSD and somatic symptoms is underscored, as well as the clinical value of early discovery of PTSD and treatment of comorbidity. Furthermore, the article illuminates knowledge about resilience and social support as protective factors.

[PTSD and Complex PTSD - Assessment, management and treatment]. / Utredning, handläggning och behandling av PTSD och CPTSD.

Post-traumatic stress disorder (PTSD) is a disruptive condition associated with great suffering. Fortunately, effective treatments are available. Assessment of children and adolescents with symptoms of PTSD is done within the child and adolescent mental health services. Adults are assessed in primary healthcare settings. In complex conditions with psychiatric comorbidity, assessment is conducted in specialist psychiatric services. Trauma-focused psychotherapy is the treatment of choice for both children and adults. Trauma-focused psychotherapy is also recommended for treating complex PTSD, despite a weaker evidence base. PTSD-specific treatment should normally be offered even in the presence of psychiatric comorbidities. Treatment of children and adolescents with PTSD and CPTSD is provided by child and adolescent mental health services. Adults can receive treatment both in primary and secondary healthcare settings, depending on symptomatology and comorbidities.

Interdisciplinary pain rehabilitation for immigrants with chronic pain who need language interpretation.

OBJECTIVE: To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately. DESIGN: Prospective multi-centre cohort study. PATIENTS: Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language. METHODS: Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the programme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme. RESULTS: Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain intensity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables. CONCLUSION: This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

Opening up mental health service delivery to cultural diversity: current situation, development and examples from three northern European countries.

There are inequalities in health among migrants and local populations in Europe. Due to migration, Germany, Norway and Sweden have become ethnic culturally diverse nations. There are barriers to mental health care access for refugees, migrants and minorities, and problems with quality of culturally sensitive care in the three countries. This is despite tax-funded health care systems based on equity in service provision. There is a need to develop culturally sensitive mental health services that respond to the increasing diversity of the populations. In this chapter, we will take a closer look at cultural diversity in the countries in question, discuss challenges and give examples of current work to open up mental health services to cultural diversity. The German example will focus on the movement of Interkulturelle Öffnung (cross-cultural opening of the health care system) and work on creating national guidelines and quality standards. From Norway, the work of the National Centre for Mental Health for the indigenous Sámi population will be presented. The Swedish example will focus on the work carried out by the Transcultural Centre. The latter is a competence centre supporting development of culturally sensitive care as an integrated part of the regional health and mental health care system in Stockholm. Finally, the relevance of mental health care for a culturally diverse population, as a part of the larger social project of building tolerant multicultural societies, will be discussed.

Samis in the city. A qualitative study of mental health and well-being among Samis in Stockholm.

Indigenous people globally suffer from poorer health than majority populations. For the Sami, the indigenous people living in the north of Norway, Sweden, Finland and Russia, physical health conditions seem to be comparable to the population in general, but there are concerns about mental health. Studies have shown a higher risk of suicide, especially for young men active in traditional reindeer herding in the north. There is less knowledge about the mental health of Samis that have migrated to the cities. In this study, we interviewed 25 Samis, recruited through convenience sampling in the Stockholm area, about their perceptions of health and well-being, the importance of the Sami background and culture, their views of mental health services and the need of adapting them to Sami needs. Throughout the process, the researchers collaborated closely with the Stockholm Sami Association, in an approach of participatory research. The interviews were analysed with thematic analysis. For the participants, a secure Sami identity and being treated with respect for their identity was seen as essential for mental health and well-being. Informants' emphasis on respect for their Sami identity and belonging can be seen as a call for restoration of basic human rights. Historical experiences, current harassments and political decisions affected their health. The informants wished caregivers to increase their knowledge of Sami history and traditions.