Attachment-based psychosocial programme for under-privileged school children with adverse life experiences in Istanbul, Turkey.

Children experiencing educational neglect are likely to experience the harm associated with adverse life experiences and a range of emotional and psychological challenges. Using attachment theory and psychosocial frameworks, we devised and implemented an intervention designed to ameliorate the deleterious effects of challenging behaviours in an elementary school situated in a deprived neighbourhood of Istanbul, Turkey. For a period of eight months, 160 pupils received a psychosocial intervention once a week. Children's patterns of behaviour, emotions, movements, interactivity, socialisation and interpersonal communications were observed during this period. Core activities of the intervention included library visits, reading, writing and listening games, maths games, drawing, animal animation, leaf making, ball games, parachuting games, colouring, hula-hoop and driver-car role plays. At the end of the intervention, one group of children made significant improvements in behavioural changes while no improvements were observed for another group. Although further research is required to generalize beyond the reference group, the findings suggest that a robust collaboration between inter-agency community partnership and universities can play a crucial role in responding to the needs of marginalized children with psychological and emotional problems.

Maternal migration and autism risk: systematic analysis.

Autism (AUT) is one of the most prevalent developmental disorders emerging during childhood, and can be amongst the most incapacitating mental disorders. Some individuals with AUT require a lifetime of supervised care. Autism Speaks reported estimated costs for 2012 at £34 billion in the UK; and $3.2 million-$126 billion in the US, Australia and Canada. Ethnicity and migration experiences appear to increase risks of AUT and relate to underlying biological risk factors. Sociobiological stress factors can affect the uterine environment, or relate to stress-induced epigenetic changes during pregnancy and delivery. Epigenetic risk factors associated with AUT also include poor pregnancy conditions, low birth weight, and congenital malformation. Recent studies report that children from migrant communities are at higher risk of AUT than children born to non-migrant mothers, with the exception of Hispanic children. This paper provides the first systematic review into prevalence and predictors of AUT with a particular focus on maternal migration stressors and epigenetic risk factors. AUT rates appear higher in certain migrant communities, potentially relating to epigenetic changes after stressful experiences. Although AUT remains a rare disorder, failures to recognize its public health urgency and local community needs continue to leave certain cultural groups at a disadvantage.

Migration and common mental disorder: an improvement in mental health over time?

Global migration is reaching record high levels and UK migrant groups comprise an increasing proportion of the total population. The migratory process causes stress that can affect mental health. There is limited consistent empirical evidence of a longitudinal nature to explain the association between migration and mental health. This review aims to examine the evidence of a relationship between migration and common mental disorder (CMD) amongst migrants over time. A comprehensive search of medical and psychiatric databases for global quantitative empirical studies investigating incidence of CMD amongst adult migrants from 1975 to July 2012 was conducted. Declines in rates of CMD amongst migrants over time were reported by two thirds of the 18 studies reviewed, less than one third of which were statistically significant. On the contrary, three studies showed an increased rate of CMD, one statistically significant. Individual psychological resources, social support, the acculturation process, cultural variations and time since relocation are identified as statistically significant protective factors against the development of CMD amongst migrants. New enlightening points include the significant impact of varying patterns of psychological distress, of which negative is the most adverse for CMD. Migration is an extremely complex process. Further clarification is needed to gain deeper understanding of the relationship between migration and CMD to address contradictions in the literature and health inequalities amongst migrants.

Is violent radicalisation associated with poverty, migration, poor self-reported health and common mental disorders?

BACKGROUND: Doctors, lawyers and criminal justice agencies need methods to assess vulnerability to violent radicalization. In synergy, public health interventions aim to prevent the emergence of risk behaviours as well as prevent and treat new illness events. This paper describes a new method of assessing vulnerability to violent radicalization, and then investigates the role of previously reported causes, including poor self-reported health, anxiety and depression, adverse life events, poverty, and migration and socio-political factors. The aim is to identify foci for preventive intervention. METHODS: A cross-sectional survey of a representative population sample of men and women aged 18-45, of Muslim heritage and recruited by quota sampling by age, gender, working status, in two English cities. The main outcomes include self-reported health, symptoms of anxiety and depression (common mental disorders), and vulnerability to violent radicalization assessed by sympathies for violent protest and terrorist acts. RESULTS: 2.4% of people showed some sympathy for violent protest and terrorist acts. Sympathy was more likely to be articulated by the under 20s, those in full time education rather than employment, those born in the UK, those speaking English at home, and high earners (>£75,000 a year). People with poor self-reported health were less likely to show sympathies for violent protest and terrorism. Anxiety and depressive symptoms, adverse life events and socio-political attitudes showed no associations. CONCLUSIONS: Sympathies for violent protest and terrorism were uncommon among men and women, aged 18-45, of Muslim heritage living in two English cities. Youth, wealth, and being in education rather than employment were risk factors.

Adult attachment style as a risk factor for maternal postnatal depression: a systematic review.

BACKGROUND: Postnatal depression (PND) is an important health problem of global relevance for maternal health and impacts on the health and wellbeing of the child over the life-course. Multinational data is hard to locate, the economic burden of PND on health care systems have been calculated in several countries, including Canada and in the UK. In Canada, health and social care costs for a mother with PND were found to be just over twice that of mothers with no mental illness. The extra community care cost for women with PND living in the UK was found to be £35.7 million per year. METHOD: We carried out a systematic search to the literature to investigate the associations between attachment style and PND, using meta-narrative analysis methods, reporting statistical data and life narratives. The following databases were searched: PsycInfo, PsycExtra Web of Science, The Cochrane Library and Pubmed. We focused on research papers that examined adult attachment styles and PND, and published between 1991 and 2013. We included any papers showing relationship between maternal adult attachment and PND. Out of 353 papers, 20 met the study inclusion criteria, representing a total of 2306 participants. Data from these 20 studies was extracted by means of a data extraction table. RESULTS: We found that attachment and PND share a common aetiology and that 'insecure adult attachment style' is an additional risk factor for PND. Of the insecure adult attachment styles, anxious styles were found to be associated with PND symptoms more frequently than avoidant or dismissing styles of attachment. CONCLUSION: More comprehensive longitudinal research would be crucial to examine possible cause-effect associations between adult attachment style (as an intergenerational construct and risk factor) and PND (as an important maternal mental health), with new screening and interventions being essential for alleviating the suffering and consequences of PND. If more is understood about the risk profile of a new or prospective mother, more can be done to prevent the illness trajectory (PND); as well as making existing screening measures and treatment options more widely available.

Treatment of eating disorders among ethnic minorities in western settings: a systematic review.

OBJECTIVES: This systematic review looked at the utilisation of treatment, access to treatment and referral of ethnic minorities for treatment of eating disorders in western settings. It also aimed to explore the barriers in access and utilisation of treatment including the role of acculturation. METHODS: The review included both qualitative and quantitative studies. The search identified a total of 2786 articles. Out of the 2786 articles, 12 articles (1 qualitative and 11 quantitative) were selected for the purpose of the research. RESULTS: The review showed that ethnic minority communities in UK and USA were far less likely to seek and receive treatment for their eating disorders and also less likely to be diagnosed and referred to eating disorder services or clinics for treatment of their eating disorders. Referral bias of ethnic minority participants to specialist eating disorder services were found in three quantitative studies (Waller et al. 2009, Becker et al. 2003, Abbas et al. 2010). The review also found that more accultured ethnic minority participants were more likely to seek treatment for their eating disorders. CONCLUSION: The above study has shown that ethnic minorities are less likely to have access to treatment for Eating Disorders.

Migration experiences, employment status and psychological distress among Somali immigrants: a mixed-method international study.

BACKGROUND: The discourse about mental health problems among migrants and refugees tends to focus on adverse pre-migration experiences; there is less investigation of the environmental conditions in which refugee migrants live, and the contrasts between these situations in different countries. This cross-national study of two samples of Somali refugees living in London (UK) and Minneapolis, Minnesota, (USA) helps to fill a gap in the literature, and is unusual in being able to compare information collected in the same way in two cities in different countries. METHODS: There were two parts to the study, focus groups to gather in-depth qualitative data and a survey of health status and quantifiable demographic and material factors. Three of the focus groups involved nineteen Somali professionals and five groups included twenty-eight lay Somalis who were living in London and Minneapolis. The quantitative survey was done with 189 Somali respondents, also living in London and Minneapolis. We used the MINI International Neuropsychiatric Interview (MINI) to assess ICD-10 and DSM-IV mental disorders. RESULTS: The overall qualitative and quantitative results suggested that challenges to masculinity, thwarted aspirations, devalued refugee identity, unemployment, legal uncertainties and longer duration of stay in the host country account for poor psychological well-being and psychiatric disorders among this group. CONCLUSION: The use of a mixed-methods approach in this international study was essential since the quantitative and qualitative data provide different layers and depth of meaning and complement each other to provide a fuller picture of complex and multi-faceted life situations of refugees and asylum seekers. The comparison between the UK and US suggests that greater flexibility of access to labour markets for this refugee group might help to promote opportunities for better integration and mental well-being.

Forced residential mobility and social support: impacts on psychiatric disorders among Somali migrants.

BACKGROUND: Somali migrants fleeing the civil war in their country face punishing journeys, the loss of homes, possessions, and bereavement. On arrival in the host country they encounter poverty, hostility, and residential instability which may also undermine their mental health. METHODS: An in-depth and semi-structured interview was used to gather detailed accommodation histories for a five year period from 142 Somali migrants recruited in community venues and primary care. Post-codes were verified and geo-mapped to calculate characteristics of residential location including deprivation indices, the number of moves and the distances between residential moves. We asked about the reasons for changing accommodation, perceived discrimination, asylum status, traumatic experiences, social support, employment and demographic factors. These factors were assessed alongside characteristics of residential mobility as correlates of ICD-10 psychiatric disorders. RESULTS: Those who were forced to move homes were more likely to have an ICD-10 psychiatric disorder (OR = 2.64, 1.16-5.98, p = 0.02) compared with those moving through their own choice. A lower risk of psychiatric disorders was found for people with larger friendship networks (0.35, 0.14-0.84, p = 0.02), for those with more confiding emotional support (0.42, 0.18-1.0, p = 0.05), and for those who had not moved during the study period (OR = 0.21, 0.07-0.62, p = 0.01). CONCLUSIONS: Forced residential mobility is a risk factor for psychiatric disorder; social support may contribute to resilience against psychiatric disorders associated with residential mobility.

A case study of organisational Cultural Competence in mental healthcare.

BACKGROUND: Ensuring Cultural Competence (CC) in health care is a mechanism to deliver culturally appropriate care and optimise recovery. In policies that promote cultural competence, the training of mental health practitioners is a key component of a culturally competent organisation. This study examines staff perceptions of CC and the integration of CC principles in a mental healthcare organisation. The purpose is to show interactions between organisational and individual processes that help or hinder recovery orientated services. METHODS: We carried out a case study of a large mental health provider using a cultural competence needs analysis. We used structured and semi-structured questionnaires to explore the perceptions of healthcare professionals located in one of the most ethnically and culturally diverse areas of England, its capital city London. RESULTS: There was some evidence that clinical staff were engaged in culturally competent activities. We found a growing awareness of cultural competence amongst staff in general, and many had attended training. However, strategic plans and procedures that promote cultural competence tended to not be well communicated to all frontline staff; whilst there was little understanding at corporate level of culturally competent clinical practices. The provider organisation had commenced a targeted recruitment campaign to recruit staff from under-represented ethnic groups and it developed collaborative working patterns with service users. CONCLUSION: There is evidence to show tentative steps towards building cultural competence in the organisation. However, further work is needed to embed cultural competence principles and practices at all levels of the organisation, for example, by introducing monitoring systems that enable organisations to benchmark their performance as a culturally capable organisation.

Introduction to the special issue: the changing use and misuse of khat (Catha edulis)--tradition, trade and tragedy.

Within the last decade the hitherto little known psychoactive substance of khat has emerged as a regional and international issue. In the Horn of Africa khat production has spurred an economic boom, but dramatic increases in consumption have raised public health concerns. Given the complexity of the topic spanning multiple academic disciplines and fields of professional practice, the need for a systematic overview is urgent. To facilitate the exchange of information, prompt interdisciplinary research and alert international organisations and governments, the authors organised an international and interdisciplinary khat conference in 2009. This special issue of the Journal of Ethnopharmacology contains articles written by different conference speakers that present the current state of knowledge and the challenges for future research and politics.

Trauma, khat and common psychotic symptoms among Somali immigrants: a quantitative study.

AIM OF THE STUDY: To investigate the relationship between (i) khat use and (ii) traumatic events, with measures of common psychotic symptoms and symptoms of anxiety and depression. To undertake this work in a Somali population of emigrants who have sought asylum in a non-conflict zone country. MATERIALS AND METHODS: A secondary analysis of data on a population sample of 180 Somali men and women. RESULTS: Frequency of khat use was not associated with common psychotic symptoms or with symptoms of anxiety and depression, nor with traumatic events in this population. Traumatic events were related to low levels of psychotic symptoms and high levels of symptoms of anxiety and depression. CONCLUSIONS: Khat use is not inevitably linked to psychotic symptoms in population samples of Somali men and women. The contrasts between these findings and those from studies in conflict zones and studies of people with mental health problems using khat suggest further investigations are necessary. These should take into account environmental and physiological interactions.

Trauma, khat and common psychotic symptoms: a quantitative study.

AIM: To investigate the relationship between (i) khat use and (ii) traumatic events, with measures of common psychotic symptoms and symptoms of anxiety and depression. To undertake this work in a Somali population of emigrants who have sought asylum in a non-conflict zone country. MATERIALS & METHODS: A secondary analysis of data on a population sample of 180 Somali men and women. RESULTS: Frequency of khat use was not associated with common psychotic symptoms or with symptoms of anxiety and depression, nor with traumatic events in this population. Traumatic events were related to low levels of psychotic symptoms and high levels of symptoms of anxiety and depression. CONCLUSIONS: Khat use is not inevitably linked to psychotic symptoms in population samples of Somali men and women. The contrasts between these findings and those from studies in conflict zones and studies of people with mental health problems using khat suggest further investigations are necessary. These should take account environmental and physiological interactions.

The stimulant khat--another door in the wall? A call for overcoming the barriers.

AIM: In this article, we comment on the current international discourse on khat, we highlight pitfalls and and suggest balanced national international regulatory actions. METHOD: A brief an focussed review of the available literature on khat and health and examples from our own research are provided. RESULTS: The use patterns of catha edulis (khat) have changed throughout the last decades. During this period khat has had a remarkable economic boom and developed from a niche crop to the backbone of the regional economy. Now it contributes to the livelihoods of millions of people. Today, khat use is often the proverbial "Door in the wall" for large parts of the populations in African and Arab countries beyond the traditional user groups. Its use is often excessive and not restricted by social regulation mechanisms. Under such conditions, problematic khat use patterns develop rapidly, exemplified by the growing group of binge users, and it gets even prevalent among especially vulnerable groups such as children, people with mental disorders or pregnant women. The currently existing scientific evidence suggests that problematic use patterns not the use per se can be linked to numerous health consequences. CONCLUSION: This paper argues that changed patterns of khat use are a burden for some of the most underdeveloped countries in the world. But the debate around khat is stuck between extreme poles arguing for prohibition or for de-regulation. Here, we call for a balanced action of governments and international organizations leaving behind the decades of debilitating debate pro vs. contra scheduling and banning khat leaves. Instead, regulation and harm-reduction measures are urgently needed. We suggest a number of steps that should be taken immediately to better understand current khat use patterns, to address noxious excesses and to relieve suffering.

Khat use and mental illness: a critical review.

Khat has been used as a stimulant plant in many parts of Africa and the Arabian Peninsula for centuries. Its current use among particular migrant communities in Europe and elsewhere has caused alarm among policy makers and health care professionals. In the United Kingdom, the debate over the psychiatric and social implications of khat use has led to a demand for stricter legal control of this stimulant plant. This paper (a) provides a historical overview of khat use, and (b) reviews the evidence for the existence of a causal link between khat use and mental illness. To do so, we undertook a detailed search of social and medical science databases for case reports, qualitative and quantitative articles on khat use and mental illness from 1945 to 2006. The validity and reliability of the studies that met our inclusion criteria were examined. Lastly, although highlighting health concerns about khat use we suggest that the debate about this popular drug in migrant populations carries elements of a 'moral panic'. There is a need for improved research on khat use and its possible association with psychiatric disorders.

Cultural competence in mental health care: a review of model evaluations.

BACKGROUND: Cultural competency is now a core requirement for mental health professionals working with culturally diverse patient groups. Cultural competency training may improve the quality of mental health care for ethnic groups. METHODS: A systematic review that included evaluated models of professional education or service delivery. RESULTS: Of 109 potential papers, only 9 included an evaluation of the model to improve the cultural competency practice and service delivery. All 9 studies were located in North America. Cultural competency included modification of clinical practice and organizational performance. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. The cultural consultation model showed evidence of significant satisfaction by clinicians using the service. No studies investigated service user experiences and outcomes. CONCLUSION: There is limited evidence on the effectiveness of cultural competency training and service delivery. Further work is required to evaluate improvement in service users' experiences and outcomes.

Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors.

BACKGROUND: There are few mental health data for Somali people. This is due to the absence of culturally validated appropriate assessment instruments and methodological challenges. We aimed to develop a culturally appropriate instrument, and address the methodological challenges and assess some risk factors for mental disorder among Somalis in London. METHODS: Following a comprehensive process of cultural adaptation of the MINI Neuropsychiatric Interview, we assessed ICD-10 mental disorders among 143 Somalis recruited from GP registers and community sites. Associations with demographic and economic characteristics, sampling venues, cultural and migration related risk factors are reported. RESULTS: A higher risk of mental disorders was found among Somalis who used Khat (OR = 10.5, 1.1-98.3) claimed asylum at entry to the UK (OR = 12.8, 2-81.4) and recruits from primary care rather than from community sites (OR = 5.9, 1.4-25.8). A lower risk of mental disorders was found amongst Somalis in employment (OR = 0.03, 0.01-0.61), and those receiving education in the UK and in Somalia (OR = 0.13, 0.02-0.92). Over a third of subjects had any mental disorder (36.4%, 28.4-44.4), mainly common mental disorders (CMD) (33.8%, 26-41.5) and post-traumatic stress disorder (PTSD) (14%, 8.8-20.8). CMD were found among 80% of those with PTSD. CONCLUSION: Public health interventions for Somalis should focus on CMD as well as PTSD, khat use and mental health screening for suicide risk and mental disorders on arrival.

Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: a qualitative study.

Migration is known to be associated with poor health outcomes for certain marginalised and socially disadvantaged populations. This paper reviews a number of reasons why residential mobility in the 'host' country may be associated with poor mental health for refugee populations and reports on a qualitative study of Somalis living in London, UK, and their beliefs about the relationship between residential mobility, poor health and health service use. Two discussion groups were undertaken with 13 Somali professionals and four groups with 21 lay Somalis in East and South London, UK. Lay Somalis did not wish to move accommodation but felt they were forced to move. Some Somali professionals believed that the nomadic history of Somalis made them more likely to elect to move in order to escape problems of living, but this was not supported by the lay group. Frequent geographical movements were seen as stressful and undesirable, disrupted family life and child development and were detrimental to well being. Residential mobility was also perceived to interfere with health care receipt and therefore should be more comprehensively assessed in larger quantitative studies.