Development and Evaluation of a Mental Health Training Program for Community Health Workers in Indonesia.

The treatment gap in mental health care in Indonesia is a critical issue due in large measure to the dearth of professional mental health staff. In response to this need, our team designed a mental health training program for existing community health workers. The training program was offered to 65 participants at 2 (two) community primary care center (Puskesmas); we evaluated the training program with quantitative and qualitative methods. We assessed the gains in knowledge using a 20-question knowledge assessment test. In addition, in Puskesmas 1, the test was repeated as a follow-up test 4 months after the training. Statistical analysis showed that the differences between pre-test and post-test scores were significant in both Puskesmas 1 (p = 0.004) and Puskesmas 2 (p < 0.001). This study concluded that the model of integrative training appears effective for preparing Indonesian CHWs to recognize and respond to needs for mental health care.

Early psychosis in Indonesia: reflections on illness and treatment.

This paper provides an overview of more than 22 years of research conducted in the central Javanese province of Yogyakarta, Indonesia, by teams of researchers associated with Gadjah Mada University and Harvard University, led by the authors of this essay. This work is placed in the context of the very limited literature on early psychosis and mental health services in Indonesia. It provides an overview of mental health services in Indonesia and of this team's research trajectory, then addresses four key domains: the cultural phenomenology of early experiences of psychotic illness; patterns of onset, with a particular focus on extremely rapid onset psychoses; patterns of care-seeking for first episode illness; and mental health services and patterns of utilization. It then discusses the importance of rapid onset psychosis for research on early psychosis, and the question of whether collinearity of rapidity of onset and rapidity of care-seeking raises questions about the long-standing finding that a short duration of untreated psychosis leads to better outcomes. It concludes by discussing difficulties of prioritizing early intervention models in settings with very low mental health resources.

Unlocking the mentally ill in Indonesia: An empirical study of the effectiveness of a "Bebas Pasung" program in Central Java.

BACKGROUND: Locking or confinement of persons with severe mental illness has been common in Indonesia. In 2010, the Ministry of Health declared a policy that persons who were locked (pasung) should be unlocked or freed (bebas) from confinement and provided mental health services. This study is an empirical evaluation of the effectiveness of one Bebas Pasung program in Indonesia at two-year follow-up. METHODS: From medical records in Soerojo Mental Hospital, Magelang, Central Java, 114 persons with severe mental illness who had been unlocked, treated, and returned to the community from four districts served by the hospital were identified. At two-year follow-up, 62 caregivers were able to be contacted and willing to participate in a study. Data were collected from hospital records about condition of the patient at time of "unlocking" and at discharge, and primary caregivers were interviewed about the previous locking and care of the patient since return, as well as experiences of caregiving. RESULTS: We provide descriptive data concerning history of illness, reasons for locking, type of confinement, and care of the individual since return. 58% of those unlocked were men, 80% had diagnoses of schizophrenia, and mean age was 35. At follow-up, 24% of this sample had been re-locked; only 44% took medications regularly, including 33% of those re-locked and 47% of those not relocked. A majority cared for themselves, half were partially or fully productive, and the quality of life of family caregivers improved significantly since their family member was unlocked, treated, and returned home. CONCLUSIONS: This program successfully unlocked, treated, and returned to their homes persons with severe mental illness living in pasung or restraints. Findings suggest such unlocking programs need to be linked more closely to community-based mental health and rehabilitation services, maintain care of the patient, and provide a path toward recovery.

Childhood maltreatment profile in a clinical population in China: a further analysis with existing data of an epidemiologic survey.

To determine the lifetime prevalence and diverse profiles of types of childhood maltreatment (CM) in a high-risk clinical sample using standardized assessment tools (Child Trauma Questionnaire, CTQ) in China, Shanghai, 2090 subjects were sampled from the Shanghai Mental Health Centre. Personality disorder (PD) was assessed using the Personality Diagnostic Questionnaire (PDQ-4+) and subjects were interviewed using the Structured Clinical Interview (SCID-II). CTQ was used to assess CM in five domains (emotional abuse, EA; physical abuse, PA; sexual abuse, SA; emotional neglect, EN; and physical neglect, PN). The prevalence estimate of EA in the sample is 22.2%, followed by 17.8% of PA, and 12.5% of SA. The prevalence estimate was more frequent in PN (65.0%) and in EN (34.0%) than in childhood abuse (EA, PA and SA). It seems that males reported more PA and females reported more SA, the older subjects reported more neglect and the younger subjects reported more abuse. There was a higher prevalence of EA and SA in borderline PD patients (44.4%, 22.5%), PA in antisocial PD patients (38.9%). Multi-PD patients reported more forms of CM in childhood. Additionally, factor analysis of CTQ items confirmed factorial validity by identifying a five-factor structure that explained 50% of the total variance. These findings support the view that prevalence of CM was commonly experienced in clinical population during their childhood, especially for subjects with PDs. Factorial validity in PN needs to be further improved, and can in part be culturally explained.

The principles of recovery-oriented mental health services: A review of the guidelines from five different countries for developing a protocol to be implemented in Yogyakarta, Indonesia.

BACKGROUND: Recovery-oriented mental health service has become the focus of global change in mental health services. Most of North industrialized countries have adopted and implemented this paradigm in the last two decades. Only recently that some developing countries are trying to follow this step. In Indonesia's case, there has been little attention to developing a recovery orientation by mental health authorities. The aim of this article is to synthesize and analyze the recovery-oriented guidelines from five industrialized countries that we can use as a primary model for developing a protocol to be implemented in community health centre in Kulonprogo District, Yogyakarta, Indonesia. METHOD: We used a narrative literature review by searching for guidelines from many different sources. We found 57 guidelines, but only 13 from five countries met the criteria, including five guidelines from Australia, one from Ireland, three from Canada, two from the UK, and two from the US. To analyze the data, we used an inductive thematic analysis to explore the themes of each principle as described by the guideline. RESULT: The results of the thematic analysis revealed seven recovery principles, including (1) cultivating positive hope, (2) establishing partnerships and collaboration, (3) ensuring organizational commitment and evaluation, (4) recognizing the consumer's rights, (5) focusing on person-centeredness and empowerment, (6) recognizing an individual's uniqueness and social context, and (7) facilitating social support,. These seven principles are not independent, rather they are interrelated and overlap each other. CONCLUSION: The principle of person-centeredness and empowerment is central to the recovery-oriented mental health system, while the principle of hope is also essential to embracing all the other principles. We will adjust and implement the result of the review in our project focusing on developing recovery-oriented mental health service in the community health center in Yogyakarta, Indonesia. We hope that this framework will be adopted by the central government in Indonesia and other developing countries.

Prevalence of personality disorders using two diagnostic systems in psychiatric outpatients in Shanghai, China: a comparison of uni-axial and multi-axial formulation.

OBJECTIVE: To compare multi-axial (DSM-IV) with uni-axial diagnostic system (CCMD-3, Chinese Classification and Diagnostic Criteria of Mental Disorders) as diagnostic methods to determine the prevalence of personality disorders (PDs) in Chinese psychiatric outpatients. METHOD: 3,075 outpatients were randomly sampled from clinical settings in China. CCMD-3 PDs were evaluated as per routine psychiatric practice. DSM-IV PDs were assessed using both self-reported questionnaire and structured clinical interview. RESULTS: The prevalence estimate for any type of PD in the total sample is 31.93% as reflected in the DSM-IV. This figure is nearly 110 times as large as the prevalence estimate for the CCMD-3. Only 9 outpatients were diagnosed with PD based on the CCMD-3. Amongst the 10 forms of DSM-IV PDs, avoidant (8.1%), obsessive-compulsive (7.6%), paranoid (6.0%), and borderline (5.8%) PDs were the most prevalent subtypes. This study found that PDs are commonly associated with the following: (i) the younger aged; (ii) single marital status; (iii) those who were not raised by their parents; (iv) introverted personalities; (v) first-time seekers of psycho-counseling treatment; and (vi) patients with co-morbid mood or anxiety disorders. CONCLUSIONS: PDs are easily overlooked when the diagnosis is made based on the CCMD-3 uni-axial diagnostic system. However, it was found that personality pathology is common in the Chinese psychiatric community when using the DSM-IV classification system. Existing evidence suggest, at least indirectly, that there are important benefits of moving towards a multi-axial diagnostic approach in psychiatric practice.

Cultural explanations of psychotic illness and care-seeking of family caregivers in Java, Indonesia.

The cultural understanding of illness among caregivers of first-episode psychotic persons is a crucial issue. Not only does it influence caregivers' care-seeking behavior and length of time until receiving medical treatment (known as the 'duration of untreated psychosis' or DUP), but it also predicts the outcome of the illness. This article aims to explore cultural understanding and care-seeking behavior among caregivers of psychotic patients in Java, Indonesia. Data for this article have been taken from two studies conducted by our research group in Yogyakarta, Indonesia. Methods of data collection include surveys, case studies, ethnographic fieldwork, and in-depth interviews. Results of analyses, within and across studies, indicate that caregivers have employed diverse cultural explanatory models in order to understand psychotic illness. Local cultural beliefs, including possession and forms of black magic, were among the most common initial concepts held by family members in relation to psychosis. This echoes broader cultural beliefs in Java. However, it was not uncommon for caregivers to also understand illness in psychological terms (such as frustration, disappointment, and stress) and attached medical explanations. Caregivers' understanding of illness also changed over time following the changing course of the illness. Both models of illness and the rapidity of care-seeking are also related to the acuteness of onset. This article concludes that it is important for mental health providers, as well as those designing systems of care, to understand the diversity and changing nature of caregivers' cultural understanding of psychotic illness.

Early intervention in psychosis: a case study on normal and pathological.

Accumulating evidence suggests that delays in receiving treatment are associated with poorer prognosis and longer periods of unneeded suffering. The duration of untreated psychosis (DUP) is considered to be one of the most important determinants of outcome in the first episode of psychosis. However, the focus on decreasing the length of untreated illness tends to overlook the difficult task of making sense of psychotic experiences during a first episode. Using a qualitative analysis of narratives obtained from interviews with an individual and her husband, we examine what delayed her seeking help, how she became convinced that she needed treatment and what this meant for her and her husband. Additionally, we look at the five-year development of both a literal and a figurative space within which both the subject and her husband came to utilize, whether consciously or unconsciously, the 'stories' of her psychotic experiences to construct a shared and even 'safe' and familiar means of spousal connection. The exploration of this shared space reveals the normative and moral values embedded in the concept of DUP and suggests alternative ways of understanding the help-seeking behaviors in early psychosis.

Conflict nightmares and trauma in Aceh.

In both the Acehnese and Indonesian languages, there is no single lexical term for "nightmare." And yet findings from a large field research project in Aceh that examined post traumatic experience during Aceh's nearly 30-year rebellion against the Indonesian state and current mental distress revealed a rich variety of dream narratives that connect directly and indirectly to respondents' past traumatic experiences. The results reported below suggest that even in a society that has a very different cultural ideology about dreams, where "nightmares" as such are not considered dreams but rather the work of mischievous spirits called jin, they are still a significant part of the trauma process. We argue that it is productive to distinguish between terrifying and repetitive dreams that recreate the traumatic moment and the more ordinary varieties of dreams that Acehnese reported to their interviewers. Nightmares that refer back to conflict events do not appear as an elaborated feature of trauma as the condition is understood by people in Aceh, but when asked further about their dreams, respondents who reported symptoms suggestive of PTSD were more likely to report PTSD-like dreams, memory intrusions that repeat the political violence of the past.

Brief interactive psychoeducation for caregivers of patients with early phase psychosis in Yogyakarta, Indonesia.

AIM: Brief psychoeducation for families of psychotic patients has been shown to significantly increase family members' knowledge of the disorder. This increase is associated with reductions in relapse and rehospitalization. The aim of this study was to assess the effectiveness of brief psychoeducation about schizophrenia to caregivers of patients in early phases of psychotic disorders in Yogyakarta, Indonesia. METHODS: This study was a prospective, randomized trial with 2 parallel groups. Subjects were patients in the early phase of psychotic disorders and their respective caregivers. Inclusion criteria included a diagnosis of acute and transient psychotic disorders, schizophrenia, schizoaffective disorder or delusional disorder. Participants were randomly assigned to either control or intervention groups by means of paired simple randomization. A brief psychoeducation was conducted for both the patients and caregivers. The interventions were conducted in 4 interactive sessions, once per week. Effectiveness was measured using standardized instruments before the intervention, and at 1 and 6 months post-intervention. Assessment instruments included the Knowledge of Psychosis (KOP), the Compliance and Relapse Assessment, the Brief Psychiatric Rating Scale and the Positive and Negative Symptoms of Schizophrenia scale. RESULTS: Interventions improved KOP scores significantly in the intervention group. The intervention group had increased regularity of follow-up with health providers and improved compliance. No statistically significant difference in relapses/rehospitalization was observed. CONCLUSIONS: This study demonstrated that brief psychoeducation with caregivers of patients with early phase psychosis was feasible in our setting, significantly improved caregivers' knowledge, and resulted in improved regularity of contact with health providers and compliance with pharmacotherapy.

Shame as a cultural index of illness and recovery from psychotic illness in Java.

OBJECTIVE: Most studies of shame have focused on stigma as a form of social response and a socio-psychological consequence of mental illness. This study aims at exploring more complex Javanese meanings of shame in relation to psychotic illness. METHOD: Six psychotic patients and their family members participated in this research. Ethnographic fieldwork was conducted in Yogyakarta, Indonesia. RESULT: Thematic analysis of the data showed that participants used shame in three different ways. First, as a cultural index of illness and recovery. Family members identified their member as being ill when they had lost their sense of shame. If a patient exhibited behavior that indicated the reemergence of shame, the family saw this as an indication of recovery. Second, as an indication of relapse. Third, as a barrier toward recovery. CONCLUSIONS: Shame is used as a cultural index of illness and recovery because it associated with the moral-behavioral control. Shame may also be regarded as a form of consciousness associated with the emergence of insight. Further study with a larger group of sample is needed to explore shame as a 'socio-cultural marker' for psychotic illness in Java.

Culture and stigma: adding moral experience to stigma theory.

Definitions and theoretical models of the stigma construct have gradually progressed from an individualistic focus towards an emphasis on stigma's social aspects. Building on other theorists' notions of stigma as a social, interpretive, or cultural process, this paper introduces the notion of stigma as an essentially moral issue in which stigmatized conditions threaten what is at stake for sufferers. The concept of moral experience, or what is most at stake for actors in a local social world, provides a new interpretive lens by which to understand the behaviors of both the stigmatized and stigmatizers, for it allows an examination of both as living with regard to what really matters and what is threatened. We hypothesize that stigma exerts its core effects by threatening the loss or diminution of what is most at stake, or by actually diminishing or destroying that lived value. We utilize two case examples of stigma--mental illness in China and first-onset schizophrenia patients in the United States--to illustrate this concept. We further utilize the Chinese example of 'face' to illustrate stigma as having dimensions that are moral-somatic (where values are linked to physical experiences) and moral-emotional (values are linked to emotional states). After reviewing literature on how existing stigma theory has led to a predominance of research assessing the individual, we conclude by outlining how the concept of moral experience may inform future stigma measurement. We propose that by identifying how stigma is a moral experience, new targets can be created for anti-stigma intervention programs and their evaluation. Further, we recommend the use of transactional methodologies and multiple perspectives and methods to more fully capture the interpersonal core of stigma as framed by theories of moral experience.

The effect of artificial selection on phenotypic plasticity in maize.

Remarkable productivity has been achieved in crop species through artificial selection and adaptation to modern agronomic practices. Whether intensive selection has changed the ability of improved cultivars to maintain high productivity across variable environments is unknown. Understanding the genetic control of phenotypic plasticity and genotype by environment (G × E) interaction will enhance crop performance predictions across diverse environments. Here we use data generated from the Genomes to Fields (G2F) Maize G × E project to assess the effect of selection on G × E variation and characterize polymorphisms associated with plasticity. Genomic regions putatively selected during modern temperate maize breeding explain less variability for yield G × E than unselected regions, indicating that improvement by breeding may have reduced G × E of modern temperate cultivars. Trends in genomic position of variants associated with stability reveal fewer genic associations and enrichment of variants 0-5000 base pairs upstream of genes, hypothetically due to control of plasticity by short-range regulatory elements.

The association between duration of untreated psychosis in first psychotic episode patients and help seeking behaviors in Jogjakarta, Indonesia.

Help seeking is predictor of prognosis in the first episode of psychotic disorders. Caregivers play a key role in deciding from whom to seek help. In Indonesia, caregivers often seek help from alternative healers first and health professionals later, which is believed to result in delayed psychiatric treatment and risk for poor prognosis. This study measured the duration of untreated psychosis (DUP) in a sample of 100 persons being treated for a first episode of psychosis in Yogyakarta, Indonesia. We attempted to measure and determine associations among caregivers' explanatory models, help seeking behaviors and DUP in this sample. The data were then statistically analyzed. The DUP for this population was very short. Most caregivers were parents or spouses (72 and 12%, respectively) and at the time of being interviewed described medical explanatory models for the psychotic symptoms (60%). A majority described having visited traditional/alternative healers prior to their visit to health professionals (67%). Despite this, the DUP was not significantly different for these two groups. Thus, first resort to traditional/alternative healers did not predict prolonged DUP. Further study with a larger sample is needed to better understand the relationship between care seeking, use of alternative healers and DUP in Indonesia.

Unlocking patients with mental disorders who were in restraints at home: a national follow-up study of China's new public mental health initiatives.

BACKGROUND: In 2005, China implemented a demonstration program known as "686" to scale-up nation-wide basic mental health services designed to improve access to evidence-based care and to promote human rights for people with severe mental disorders. As part of the 686 Program, teams "unlocked" and provided continuous mental health care to people with severe mental disorders who were found in restraints and largely untreated in their family homes. We implemented a nation-wide two-stage follow-up study to measure the effectiveness and sustainability of the "unlocking and treatment" intervention and its impact on the well-being of patients' families. METHODS: 266 patients unlocked from 2005 in "686" demonstration sites across China were recruited in Stage One of the study in 2009. In 2012, 230 of the 266 cases were re-interviewed (the Stage Two study). Outcome measures included the patient medication adherence and social functioning, family burden ratings, and relocking rate. We utilized pre-post tests to analyze the changes over time following the unlocking efforts. RESULTS: 96% of patients were diagnosed with schizophrenia. Prior to unlocking, their total time locked ranged from two weeks to 28 years, with 32% having been locked multiple times. The number of persons regularly taking medicines increased from one person at the time of unlocking to 74% in 2009 and 76% in 2012. Pre-post tests showed sustained improvement in patient social functioning and significant reductions in family burden. Over 92% of patients remained free of restraints in 2012. CONCLUSION: Practice-based evidence from our study suggests an important model for protecting the human rights of people with mental disorders and keeping them free of restraints can be achieved by providing accessible, community based mental health services with continuity of care. China's "686" Program can inform similar efforts in low-resource settings where community locking of patients is practiced.

"What matters most:" a cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma.

To understand Chinese immigrants' experiences with mental illness stigma and mental health disparities, we integrate frameworks of 'structural vulnerability' and 'moral experience' to identify how interaction between structural discrimination and cultural engagements might shape stigma. Fifty Chinese immigrants, including 64% Fuzhounese immigrants who experienced particularly harsh socio-economical deprivation, from two Chinese bilingual psychiatric inpatient units in New York City were interviewed from 2006 to 2010 about their experiences of mental illness stigma. Interview questions were derived from 4 stigma measures, covering various life domains. Participants were asked to elaborate their rating of measure items, and thus provided open-ended, narrative data. Analysis of the narrative data followed a deductive approach, guided by frameworks of structural discrimination and "what matters most" - a cultural mechanism signifying meaningful participation in the community. After identifying initial coding classifications, analysis focused on the interface between the two main concepts. Results indicated that experiences with mental illness stigma were contingent on the degree to which immigrants were able to participate in work to achieve "what mattered most" in their cultural context, i.e., accumulation of financial resources. Structural vulnerability - being situated in an inferior position when facing structural discrimination - made access to affordable mental health services challenging. As such, structural discrimination increased healthcare spending and interfered with financial accumulation, often resulting in future treatment nonadherence and enforcing mental health disparities. Study participants' internalizing their structurally-vulnerable position further led to a depreciated sense of self, resulting in a reduced capacity to advocate for healthcare system changes. Paradoxically, the multi-layered structural marginalization experienced by Chinese immigrants with mental illness allowed those who maintained capacity to work to retain social status even while holding a mental illness status. Mental health providers may prioritize work participation to shift service users' positions within the hierarchy of structural vulnerability.

Age and remission of personality pathology in the psychotic disorders compared to mood and/or anxiety disorders.

In order to explore age-related differences in personality pathology between psychotic disorder (PSD) and mood and/or anxiety disorder (MAD) among psychiatric outpatients, 2,354 subjects were sampled randomly from outpatients in Shanghai and divided into two groups: PSD (N = 951) and MAD (N = 1403). Dimensional scores for personality disorder (PD) traits were assessed by using a self-reported personality diagnostic questionnaire (PDQ4+). Significant age differences were observed in most of the PD traits in MAD patients. Cluster B and C PD traits displayed an apparent decrease with age in MAD group, but such decline trend was not evident in PSD group. In both groups, the decline of self-reported Cluster A PD traits were less visible than the other clusters. Age-related mellowing of some PD traits such as "dramatic, erratic, anxious" occurred primarily in MAD patients; however the same traits in PSD patients appear to be less resistant to aging. Besides, "old eccentric" PD traits in both MAD and PSD patients seem to be maintained and less modified by aging.

Current legislation on admission of mentally ill patients in China.

OBJECTIVE: To date, there is no systematic analysis of mental health laws and their implementation across the People's Republic of China. This article aims to describe and analyze current legal frameworks for voluntary and involuntary admissions of mentally ill patients in the five cities of China that currently have municipal mental health regulations. METHODS: Information on the legislation and practice of involuntary admission in the five cities was gathered and assessed using the "WHO Checklist on Mental Health Legislation." The checklist was completed for each city by a group of psychiatrists trained in mental health legislation. RESULTS: Although the mental health regulations in these five cities cover the basic principles needed to meet international standards of mental health legislation, some defects in the legislation remain. In particular, these regulations lack detail in specifying procedures for dealing with admission and treatment and lack oversight and review mechanisms and procedures for appeal of involuntary admission and treatment. CONCLUSIONS: A more comprehensive and enforceable national mental health act is needed in order to ensure the rights of persons suffering mental illness in terms of admission and treatment procedures. In addition, more research is needed to understand how the current municipal regulations of mental health services in these cities are implemented in routine practice.