Does "Susto" Really Exist? Indigenous Knowledge and Fright Disorders Among Q'eqchi' Maya in Belize.

Susto is one of the most common disorders referenced in the medical anthropological and cultural psychiatric literature. This article questions if "susto" as understood in cultural psychiatric terms, especially in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), is in fact a single "cultural concept of distress." There is extensive cross-cultural and intracultural variability regarding fright-related disorders in the ethnographic literature. What is often labeled "susto" may be in reality a variety of distinct disorders, or lacking in the two signature components found in the cultural psychiatric literature: the existence of a "fright," and subsequent soul loss. There has been significant polysemic and geographical drift in the idiom label, the result of colonialism in Mesoamerica, which has overlayed but not necessarily supplanted local knowledge. Using data from fifteen years of research with Q'eqchi' (Maya) healers and their patients, we demonstrate how important variability in signs, symptoms, diagnosis, treatment, and prognosis of fright-related disorders renders any simple declaration that this is a singular "susto" problematic. We argue for a careful consideration of the knowledge of Indigenous medical specialists charged with treating fright-related disorders and against the inclination to view variability as insignificant. Such consideration suggests that Indigenous forms of fright-related disorder are not susto as presented commonly in the DSM and cultural psychiatric literature.

Black American Maternal Prenatal Choline, Offspring Gestational Age at Birth, and Developmental Predisposition to Mental Illness.

Black Americans have increased risk for schizophrenia and other mental illnesses with prenatal origins. Prenatal choline promotes infant brain development and behavioral outcomes, but choline has not been specifically assessed in Black Americans. Pregnant women (N = 183, N = 25 Black Americans) enrolled in a study of prenatal stressors and interactions with prenatal choline. Black American women had lower 16-week gestation plasma choline than Whites. Lower choline was not related to obesity, income, or metabolic genotypes. Pregnant women in rural Uganda have higher choline levels than Black American women. Black Americans' lower choline was associated with higher hair cortisol, indicative of higher stress. Lower maternal choline was associated with offsprings' lower gestational age at birth and with decreased auditory P50 inhibition, a marker of inhibitory neuron development. Behavioral development was assessed on the Infant Behavior Questionnaire-R-SF (IBQ-R) at 3 months. Lower Black American maternal gestational choline was associated with lower infant IBQ-R Orienting/Regulation, indicating decreased attention and relation to caregivers. Additional evidence for developmental effects of choline in Black Americans comes from a randomized clinical trial of gestational phosphatidylcholine supplementation versus placebo that included 15 Black Americans. Phosphatidylcholine increased gestational age at birth and newborn P50 inhibition and decreased Social Withdrawn and Attention problems at 40 months of age in Black Americans' offspring compared to placebo. Inhibitory and behavioral deficits associated with lower prenatal choline in offspring of Black American women indicate potential developmental predispositions to later mental illnesses that might be ameliorated by prenatal choline or phosphatidylcholine supplementation.

Conceptualising and addressing mental disorders amongst Muslim communities: Approaches from the Islamic Golden Age.

Although Islam is the world's second-largest religion, there continues to be misconceptions and an overall lack of awareness regarding the religious and social worlds that make up the global Muslim community. This is particularly concerning when examining notions of mental ill-health, where a lack of cultural awareness, understanding, and sensitivity can impede adequate treatment. As a global religion, Islam is practiced within various cultural milieus, and, given the centrality of faith amongst Muslim communities, a conflation of religion and culture can occur when attempting to understand mental health paradigms. Whilst much of the discourse regarding Muslim mental health centres on cultural formulations, this article discusses how, historically, conceptualisations relating to medicine and mental health were ensconced within the particular medical paradigm of the day. Specifically, it considers the frameworks within which mental health and illness were understood within the medieval Muslim medical tradition and their relevance to contemporary debates in psychology and psychiatry. In sum, this paper seeks to demonstrate that cultural formulations of mental illness, often viewed as "Islamic", are distinct from historical Islamic approaches to mental health which employed contemporaneous medical discourse and which act as the reference marker for the emergent revivalist Islamic psychology movement seen today.

Part II: using an integrated case model for delivering mental health services in general practice for Pacific people.

OBJECTIVE: To discuss an alternative model for delivering mental health services to Pacific people in general practice. METHODS: Review of primary healthcare models which attempt to integrate behavioural healthcare with general practice. RESULTS: There is some evidence that relationship-based collaborative models may improve both mental and physical health. Such a model has been implemented successfully by Alaskan Native Americans. CONCLUSION: An integrated model of healthcare incorporating Pacific cultural values may reduce stigma and improve engagement and efficacy in delivering mental health treatment to Pacific people, their families and communities.

Pluralism and practicality: village health workers' responses to contested meanings of mental illness in Southern Malawi.

The individual and social construction of psychological distress is fundamental to help-seeking and the extent to which interventions are seen as credible. Where pluralistic attributions for mental health problems predominate, the development of global mental health (GMH) interventions in the form of task-shifting approaches create increased access to new ways of understanding and responding to distress. However, little is known about how participants in these initiatives manage these encounters. This qualitative study in Malawi explored village-based health workers' (HSAs) and patients' and carers' views of the causes of distress and how these beliefs influenced help-seeking and the health workers' response.Eight HSAs and nine paired patients/carers were interviewed separately to enable each of nine experiences of distress to be explored. Findings revealed a complex set of personal, social and cultural influences that informed causative attributions and help-seeking decisions. Patients/carers viewed psychosocial stresses as compelling explanations and readily reported others attributing their distress to supernatural causes (bewitchment). Yet attributional beliefs alone were not the only influence over help-seeking, which evolved pragmatically in response to the impact of treatments and social pressure for conformity. In turn HSAs navigated the interactions with patients/carers by emphasising the biomedical approach and discrediting bewitchment attributions. This caused tensions when biomedical interventions were unhelpful or the traditional healers' approach proved beneficial.Conclusions add to the call for such task-shifting approaches to work with communities to discern authentic and practical responses to mental distress that mirror the 'pluralism and pragmatism' found in the communities they serve.

"Madness and Despair are a Force": Global Mental Health, and How People and Cultures Challenge the Hegemony of Western Psychiatry.

The author suggests to consider some important hidden connections in Global Mental Health (GMH) discourse and interventions, above all the political meaning of suffering and symptoms, the power of psychiatric diagnostic categories (both Western and traditional) to name and to occult at once other conflicts, and the implicit criticism expressed by so-called local healing knowledge and its epistemologies. These issues, by emphasizing the importance to explore other ontologies, help to understand the perplexity and resistance that GMH and its agenda meet among many scholars and professionals, who denounce the risks of reproducing and globalizing Western hegemonic values concerning health, illness, and healing.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population.

OBJECTIVE: In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity. METHODS: We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language. RESULTS: Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits. CONCLUSIONS: Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

A biocultural approach to psychiatric illnesses.

RATIONALE: As a species, humans are vulnerable to numerous mental disorders, including depression and schizophrenia. This susceptibility may be due to the evolution of our large, complex brains, or perhaps because these illnesses counterintuitively confer some adaptive advantage. Additionally, cultural and biological factors may contribute to susceptibility and variation in mental illness experience and expression. Taking a holistic perspective could strengthen our understanding of these illnesses in diverse cultural contexts. OBJECTIVES: This paper reviews some of these potential factors and contextualizes mental disorders within a biocultural framework. RESULTS: There is growing evidence that suggests cultural norms may influence inflammation, neurotransmitters, and neurobiology, as well as the illness experience. Specific examples include variation in schizophrenia delusions between countries, differences in links between inflammation and emotion between the United States and Japan, and differences in brain activity between Caucasian and Asian participants indicating that cultural values may moderate cognitive processes related to social cognition and interoception. CONCLUSIONS: Research agendas that are grounded in an appreciation of biocultural diversity as it relates to psychiatric illness represent key areas for truly interdisciplinary research that can result in culturally sensitive treatments and highlight possible biological variation affecting medical treatment.

Ethnopsychopharmacology study of patients' beliefs regarding concerns about and necessity of taking psychiatric medications.

OBJECTIVE: The aim of this study was to examine whether or not cultural differences influence beliefs about the necessity of taking prescribed psychiatric drugs and concern about their adverse effects in psychiatric outpatients in Spain, Argentina, and Venezuela. METHODS: This cross-sectional study included 1,372 adult psychiatric outpatients using 2,438 psychotropic drugs and was designed to assess outpatients' beliefs about their prescribed medication. Patients completed sociodemographic, clinical questionnaires, and the Beliefs about Medicines Questionnaire Specific Scale and registered scores ranging from 1 to 5 on each of two subscales: concern and necessity. A "necessity-concern differential" was obtained by calculating the difference (range -4 to +4). RESULTS: The global score, including all drugs in the total sample, had a mean necessity score of 3.50 ± 0.95, a mean concern score of 2.97 ± 0.99, and a mean differential score of 0.54 ± 1.42. The concern and necessity mean scores varied significantly across these three culturally Hispanic countries, probably across drug classes, and were associated with treatment duration. On the other hand, age and education played a very limited role. CONCLUSIONS: Understanding the diverse effects of culture and society on these attitudes is highly relevant for the development of responsive mental health services in multicultural societies.

Evaluation of the Integrated Intervention for Dual Problems and Early Action Among Latino Immigrants With Co-occurring Mental Health and Substance Misuse Symptoms: A Randomized Clinical Trial.

Importance: Immigrants are at an increased risk for co-occurring mental health and substance misuse symptoms; however, effective treatments are lacking. Objective: To evaluate the effectiveness of the Integrated Intervention for Dual Problems and Early Action (IIDEA) program compared with enhanced usual care. Design, Setting, and Participants: This effectiveness randomized clinical trial was conducted from September 2, 2014, to February 2, 2017, in 17 clinics or emergency departments and 24 community sites in Boston, Massachusetts, as well as in Madrid and Barcelona, Spain. Equal randomization (1:1) in 2-person blocks was used, assigning participants to either the IIDEA treatment group (n = 172) or the enhanced usual care control group (n = 169). Intent-to-treat analyses assessed effectiveness, and post hoc analyses examined whether results varied by symptom severity or treatment dose. Eligible participants were between 18 and 70 years of age, self-identified as Latino, screened positive for co-occurring symptoms, and were not receiving specialty behavioral health services. Interventions: Participants were randomized to a 10-session IIDEA treatment or to enhanced usual care. Main Outcomes and Measures: Primary outcomes were changes in alcohol and drug misuse and results of a urine test for drug metabolites but not for alcohol misuse. Secondary outcomes were symptoms of depression, generalized anxiety, posttraumatic stress disorder, and overall mental health. Results: In total, 341 participants were randomized to either the IIDEA treatment group (n = 172; 94 [54.7%] female, mean [SD] age, 33.5 [11.6] years) or the enhanced usual care control group (n = 169; 80 [47.3%] female, mean [SD] age, 34.3 [11.8] years). No statistically significant effects of IIDEA were found for primary drug and alcohol outcomes (ASI Lite-drug score: ß = -0.02 [SE, 0.69; P = .88; Cohen d, 0.00; 95% CI, -0.17 to 0.17]; ASI Lite-alcohol score: ß = -0.01 [SE, 1.19; P = .66; Cohen d, 0.00; 95% CI, -0.12 to 0.12]; urine drug test result: ß = -0.36 [SE, 0.43; P = .50; OR, 0.70; 95% CI, 0.30-1.61]), but statistically significant effects were observed for secondary mental health outcomes. The IIDEA treatment was effective in reducing depressive symptoms per the Public Health Questionnaire-9 score (ß = -1.14; SE, 0.47; P = .02; Cohen d, 0.20 [95% CI, 0.04-0.36]), posttraumatic stress disorder symptoms per the Posttraumatic Stress Disorder Checklist-5 score (ß = -3.23; SE, 1.59; P = .04; Cohen d, 0.25 [95% CI, 0.01-0.37]), and overall mental health symptoms per the Hopkins Symptom Checklist-20 (ß = -0.20; SE, 0.07; P = .01; Cohen d, 0.25 [95% CI, 0.08-0.42]) and composite mental health (ß = -3.70; SE, 1.75; P = .04; Cohen d, 0.19 [95% CI, 0.01-0.36]) scores at the 6-month follow-up. Exploratory analyses suggested that 6-month treatment effects occurred for patients whose drug misuse was moderate to severe at the baseline assessment. Among patients with moderate to severe substance misuse, IIDEA substantially reduced substance use per the urine test results (odds ratio, 0.25 [95% CI, 0.09-0.67]; P = .01). Treatment dose showed small to large effect sizes by outcome. Conclusions and Relevance: The IIDEA treatment did not change drug misuse but did improve secondary mental health and substance misuse outcomes for a heterogeneous population with moderate to severe symptoms; this finding provides a path for treating Latino immigrants with co-occurring mental health and substance misuse symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT02038855.

'We need to not be footnotes anymore': understanding Métis people's experiences with mental health and wellness in British Columbia, Canada.

OBJECTIVES: This article aims to contribute to an increased understanding of Métis people's experiences with respect to mental health and wellness through sharing the perspectives, journeys and needs of Métis people in British Columbia (BC), Canada. STUDY DESIGN: This research utilized qualitative methods, within an Indigenous research paradigm, as a formative approach to understanding Métis people's experiences with mental health. METHODS: Participants were recruited in partnership with Métis communities and urban Indigenous organizations, through the distribution of online and hard copy posters. Semistructured, conversational interviews were conducted with 33 Métis participants, including 23 women and 10 men, aged 19-84 years (average = 46 years). Data were thematically analyzed using constant comparison analysis. RESULTS: Mental health was recognized as a priority for Métis people in BC, as participants emphasized the importance of addressing mental health disparities for Métis people, and the inequities in which they are rooted. They also spoke about a need for increased access to culturally responsive health care-spanning both Western and traditional systems. CONCLUSIONS: Increased research is needed to highlight and understand the experiences of Métis people, both within BC and across Canada, to help to reshape the health-care system to become more inclusive of and responsive to Métis needs.

Blood, Sweat, and/or Tears: Comparing Nervios Symptom Descriptions in Honduras.

With the aim of advancing the cross-cultural investigation of the folk illness nervios, I conducted a dual-sited comparative study of symptom descriptions among two diverse research settings in Honduras. Baer et al. (Cult Med Psychiatry 27(3):315-337, 2003) used cultural consensus modeling (CCM) to confirm a core description of nervios among four Latino groups in the US, Mexico, and Guatemala, but observed that overall agreement and average competence in a shared illness model decreased along a gradient from presumably more-to-less economically developed sites. This has left unresolved whether such variation extends to other Latin American regions. This paper is an exploratory analysis of inter- and intracultural variation in nervios symptom descriptions by 50 Hondurans from the market town of Copán Ruinas (n = 25) and city of San Pedro Sula (n = 25). I performed CCM using a combination of free-listing, pile-sorting, and rating activities to establish if respondents across sites share a single model of nervios. I found consensus for the San Pedro Sula subsample, but not for Copán Ruinas or for the overall sample. Results suggest nervios is constitutive of differing forms of distress ranging from chronic illness to acute suffering, as well as anger- and panic-based manifestations that overlap with biomedical ideas about depression, anxiety, and panic disorder. This variation derives in part from demographic factors such as age, gender, and residence, but may also result from ethnic and regional diversity among subsamples. However, consensus only being present among San Pedro Sula respondents suggests their greater awareness of cultural distinctions between biomedical and folk medical knowledge, which is likely due to their exposure to manifold health frameworks in those settings.

[Brua and psychiatry: A pilot study among Dutch-Antillean patients in the Netherlands]. / Brua en psychiatrie: een pilotstudie onder patiënten in Nederland afkomstig van de voormalige Nederlandse Antillen.

BACKGROUND: Individuals native to Aruba, Bonaire, and Curaçao, the abc islands of the former Netherlands Antilles, often attribute their complaints to brua, although they seldom discuss this with health professionals. This may have a negative influence on the therapeutic relationship and diagnostic processes.
AIM: To explore the role of brua in the illness perception of psychiatric patients in the Netherlands who were originally from the abc islands.
METHOD: A random sample of patients under treatment at Parnassia Psychiatric Institute in The Hague were interviewed with the aid of a semi-structured questionnaire.
RESULTS: Of the 18 psychiatric patients interviewed, 10 (56%) believed in brua, and 3 (17%) considered it the cause of their disease. Although none of the interviewees admitted to an active involvement in brua, 8 (44%) had been in touch with a traditional healer and 9 (50%) possessed artifacts meant to provide protection against evil. Regarding the usefulness of discussing brua with health professionals, opinions were divided.
CONCLUSION: Psychiatric patients in the Netherlands native to the abc islands are all knowledgeable of brua, with more than half of them believing in it. Despite the fear and shame that people often experience, making brua fit for discussion in clinical practice would improve the relationship between health professional and patient, yielding further opportunities for diagnosis and treatment.

"We are like co-wives": Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda.

BACKGROUND: Early identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers' views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda. METHODS: In-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental ill-health in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians' willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis. RESULTS: Traditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them. CONCLUSION: Potential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians.

Development of a spirituality-infused cognitive behavioral intervention for individuals with serious mental illnesses.

OBJECTIVE: Spirituality offers a vital coping resource that can bolster mental health and psychosocial well-being for individuals with serious mental illnesses (SMI). However, limited research on spirituality-infused evidence-based interventions exists to assist providers in mobilizing spirituality as a mental health resource. This article presents the cognitive-behavioral intervention Spiritual Strategies for Psychosocial Recovery (SSPR), developed to promote recovery among ethnoculturally diverse individuals with SMI by strengthening their coping mechanisms for internal and external distress through spiritual means. METHODS: SSPR was developed in 5 steps: (1) observation of current recovery services at a partnering psychosocial rehabilitation center; (2) creation of a treatment manual based on extant literature, the authors' evidence-based practice expertise, and observational data; (3) testing of specific SSPR skills with consumers; (4) refinement of the manual by using testing data; and (5) testing of the manual for feasibility with 37 consumers. RESULTS: Initial feasibility testing indicated that the intervention was accepted and valued by participants and providers; did not trigger psychiatric disturbances; and provided accessible spirituality-based distress coping tools for helping participants manage psychological difficulties in the community. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: SSPR and its nondenominational spirituality-based distress coping skills appear to be well tolerated by consumers and providers. Thus, SSPR might be useful for providers seeking to address consumers' distress coping by capitalizing on their existing or potential spiritual strengths. Future research is needed to evaluate the intervention's effectiveness with randomized controlled trial designs in clinical and community settings. (PsycINFO Database Record

Holy local system: religious treatment of mental sickness in rural China.

Kleinman pioneered the use of intensive case studies in China and elsewhere. Drawing on this approach, this paper shows how two rural Chinese converts to Christianity recovered from prolonged mental sickness incurred during the Cultural Revolution many years earlier. The apparent 'cure' is part of local narrative in which rural Chinese Christians' first contact with Christianity has the pragmatic aim of seeking treatment to relieve physical pain, but leads to conversion and believed divine deliverance from psychological as well as physical suffering. In acquiring what they regard as new moral life and becoming dignified 'divine selves', they adopt new language and behavior and subtly change their relationships with family and the local power structure, thereby establishing a 'holy local system' that is regarded as able to withstand external crises and temporary setbacks. Setting up the holy local system highlights the inadequacy of rural bio-medical assistance, provides treatment for sickness and pain often blamed on Chinese society's relentless pursuit of economic development, and so introduces some compensatory if illusory rural stability.

Lip service: Public mental health services and the care of Aboriginal and Torres Strait Islander peoples.

The failure of public mental services in Australia to provide care deemed culturally safe for Aboriginal and Torres Strait Islander people has persisted despite several national reports and policies that have attempted to promote positive service change. Nurses represent the largest professional group practising within these services. This article reports on a multisited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about public mental health services and the services they provided to Aboriginal and Torres Strait Islander people. During the fieldwork, mental health nurses described the constricting effect of the biomedical paradigm of mental illness on their abilities to provide authentic holistic care focused on social and emotional well-being. Despite being the most numerous professional group in mental health services, the speciality of mental health nursing appears unable to change this situation and in many cases maintain this status quo to the potential detriment of their Aboriginal and Torres Strait Islander service users.

Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways.

We examined the scope of collaborative care for persons with mental illness as implemented by traditional healers, faith healers, and biomedical care providers. We conducted semistructured focus group discussions in Ghana, Kenya, and Nigeria with traditional healers, faith healers, biomedical care providers, patients, and their caregivers. Transcribed data were thematically analyzed. A barrier to collaboration was distrust, influenced by factionalism, charlatanism, perceptions of superiority, limited roles, and responsibilities. Pathways to better collaboration were education, formal policy recognition and regulation, and acceptance of mutual responsibility. This study provides a novel cross-national insight into the perspectives of collaboration from four stakeholder groups. Collaboration was viewed as a means to reach their own goals, rooted in a deep sense of distrust and superiority. In the absence of openness, understanding, and respect for each other, efficient collaboration remains remote. The strongest foundation for mutual collaboration is a shared sense of responsibility for patient well-being.