People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India.

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n = 647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n = 649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b = -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

Cultivating distress: cotton, caste and farmer suicides in India.

Nearly 4,00,000 farmers committed suicide in India between 1995 and 2018. This translates into approximately 48 suicides every day. The majority of suicides were those from 'backwarded' castes including Dalit farmers. This ethnographic study on cotton farmer suicide reports narratives of surviving Dalit families. The results reveal that financial and moral debt when accrued within a web of family and caste-related relationships result in patterns of personal and familial humiliation, producing a profound sense of hopelessness in the Self. This loss of hope and pervasive humiliation is 'cultivated' by a cascade of decisions taken by others with little or no responsibility to the farmers and the land they hope to cultivate as they follow different cultural and financial logic. Suicide resolves the farmers' humiliation and is a logical conclusion to the farmer's distress, which results from a reconfiguration of agricultural spaces into socially toxic places, in turn framing a local panopticon. The current corona virus pandemic is likely to impact adversely on peoples who are culturally distanced.

Decolonising the medical curriculum: psychiatry faces particular challenges.

Colonial thinking runs deep in psychiatry. Recent anti-racist statements from the APA and RCPsych are to be welcomed. However, we argue that if it is to really tackle deep-seated racism and decolonise its curriculum, the discipline will need to critically interrogate the origins of some of its fundamental assumptions, values and priorities. This will not be an easy task. By its very nature, the quest to decolonise is fraught with contradictions and difficulties. However, we make the case that this moment presents an opportunity for psychiatry to engage positively with other forms of critical reflection on structures of power/knowledge in the field of mental health. We propose a number of paths along which progress might be made.

Mental health ecologies and urban wellbeing.

How might urban mental health be understood when animals reconfigure human wellbeing in the lived city? Drawing upon ethnographic fieldwork on people and macaques in New Delhi and forging novel conversations between urban studies, ecology and psychiatry, our ontology of urban mental health moves from lived experience of the built environment to those configured by dwelling with various interlocutors: animals, astral bodies and supernatural currents. These relations create microspaces of wellbeing, keeping forces of urban precarity at bay. This paper discusses mental health ecologies in different registers: subjectivity being environmental, its scale being relational rather than binary, enmeshed in the dynamics of other-than-human life, and involving conversations between medical and vernacular practices rather than hierarchies of knowledge.

How coloniality shapes the making of Latin American psychologists: ethnographic evidence from Ecuador.

This paper provides ethnographic evidence on how coloniality shapes the making of Latin American psychologists. A critical ethnography was conducted at a psychology training institution in Ecuador, consisting of twelve months of participant observation; forty-one semi-structured interviews; and analysis of academic discourse, photos, videos and relevant social media content. The research was guided by the tradition of Critical Psychology - specifically Liberation Psychology - and Critical Discourse Analysis. Findings suggest the pervasiveness of coloniality in the making of Ecuadorian psychologists and, hypothetically, of others in Latin America and the wider Global South. Interpretations also highlight the non-essentialist, non-dichotomist, 'messy' nature of such processes, a consideration which may advance current ethical and analytical debates on decolonisation. Echoing ongoing critical arguments, authors suggest that a 'help-as-war' metaphor is a category with potential value to contribute to such advancement, an approach that has important theoretical and pragmatic implications for researchers and practitioners.

Why stay? Resilience in haemophilia physicians in the 1980s.

AIMS: The occurrence of AIDS in 1980s posed difficult problems for haemophilia clinicians worldwide. The impact of these events is substantial, and the events continue to be subject to judicial proceedings and publications. The stance of haemophilia physicians, particularly their professional resilience, is of importance and remains unexamined. METHODS: Deploying oral histories informed by literature review of scientific publications and past inquiry reports, this qualitative study addresses how physicians continued to work in haemophilia during those years and attributes that contributed to their resilience. RESULTS AND CONCLUSIONS: Experience and role in laboratory aspects were of value in handling and communicating uncertainty. Collegiality, peer support and scholarship were important in sustaining their roles, in clinical decision-making and re-instating confidence in the therapeutic relationship during the toughest years of their practice.

Informed consent in psychiatry outpatients.

Background & objectives: Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods: The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results: A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions: Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

History, violence and collective memory: Implications for mental health in Ecuador.

National histories of violence shape experiences of suffering and the ways that mental health professionals respond to them. In Ecuador, mental health literature addressing this crucial issue is scarce and little debated. In contrast, local psychiatrists and psychologists within the country face contemporary challenges that are deeply rooted in a violent colonial past and the perpetuation of its fundamental ethos. This paper critically reviews relevant literature on collective memory and historical trauma, and focuses on Ecuador as a case study on how to incorporate history into modern mental health challenges. The discussion poses key questions and outlines possible ways for Ecuador to address the link between history and mental health, including insights from countries that have struggled with their violent pasts. This paper contributes to ongoing international debate on the role of cultural history in mental health with implications for social scientists and practising clinicians in former colonised nations.

Islamophobia in the National Health Service: an ethnography of institutional racism in PREVENT's counter-radicalisation policy.

In 2015, the UK government made its counter-radicalisation policy a statutory duty for all National Health Service (NHS) staff. Staff are now tasked to identify and report individuals they suspect may be vulnerable to radicalisation. Prevent training employs a combination of psychological and ideological frames to convey the meaning of radicalisation to healthcare staff, but studies have shown that the threat of terrorism is racialised as well. The guiding question of our ethnography is: how is counter-radicalisation training understood and practiced by healthcare professionals? A frame analysis draws upon 2 years of ethnographic fieldwork, which includes participant observation in Prevent training and NHS staff interviews. This article demonstrates how Prevent engages in performative colour-blindness - the active recognition and dismissal of the race frame which associates racialised Muslims with the threat of terrorism. It concludes with a discussion of institutional racism in the NHS - how racialised policies like Prevent impact the minutia of clinical interactions; how the pretence of a 'post-racial' society obscures institutional racism; how psychologisation is integral to the performance of colour-blindness; and why it is difficult to address the racism associated with colourblind policies which purport to address the threat of the Far-Right.

Keeping Our Mouths Shut: The Fear and Racialized Self-Censorship of British Healthcare Professionals in PREVENT Training.

The PREVENT policy introduced a duty for British health professionals to identify and report patients they suspect may be vulnerable towards radicalisation. Research on PREVENT's impact in healthcare is scant, especially on the lived experiences of staff. This study examined individual interviews with 16 critical National Health Service (NHS) professionals who participated in mandatory PREVENT counter-radicalisation training, half of whom are Muslims. Results reveal two themes underlying the self-censorship healthcare staff. The first theme is fear, which critical NHS staff experienced as a result of the political and moral subscript underlying PREVENT training: the 'good' position is to accept the PREVENT duty, and the 'bad' position is to reject it. This fear is experienced more acutely by British Muslim healthcare staff. The second theme relates to the structures which extend beyond PREVENT but nonetheless contribute to self-censorship: distrustful settings in which the gaze of unknown colleagues stifles personal expression; reluctant trainers who admit PREVENT may be unethical but nonetheless relinquish responsibility from the act of training; and socio-political conditions affecting the NHS which overwhelm staff with other concerns. This paper argues that counter-terrorism within healthcare settings may reveal racist structures which disproportionality impact British Muslims, and raises questions regarding freedom of conscience.

Generating toxic landscapes: impact on well-being of cotton farmers in Telangana, India.

Existing literature demonstrates agro-chemicals result in physical toxicity and damages human health, flora and fauna. However, little is known about how such 'toxicity' relates to mental well-being and social suffering. This paper aims to demonstrate how local, national and international vectors are interlinked to shape social distress among cotton farmers in India. Ethnographic interviews and focus group discussions were conducted in a cotton-growing village of the Warangal district, Telangana state, India. The results advance the concept of counter therapeutic spaces and hypothesise that toxic landscapes emerge through a dynamic interaction between dispersed agencies that interact and reconfigure agricultural spaces into socially toxic places. The paper argues that the disciplines of public health and agriculture suffer from a failure of imagination to forge vital interdisciplinary links that could address farmer suffering. Unpacking local ecologies of farmer suffering offer innovative ways for enhancing mental health policy and interventions in India.

Prevent: what is pre-criminal space?

Prevent is a UK-wide programme within the government's anti-terrorism strategy aimed at stopping individuals from supporting or taking part in terrorist activities. NHS England's Prevent Training and Competencies Framework requires health professionals to understand the concept of pre-criminal space. This article examines pre-criminal space, a new term which refers to a period of time during which a person is referred to a specific Prevent-related safeguarding panel, Channel. It is unclear what the concept of pre-criminal space adds to the Prevent programme. The term should be either clarified or removed from the Framework.

How do psychiatrists in India construct their professional identity? A critical literature review.

Psychiatric practice in India is marked by an increasing gulf between largely urban-based mental health professionals and a majority rural population. Based on the premise that any engagement is a mutually constructed humane process, an understanding of the culture of psychiatry including social process of local knowledge acquisition by trainee psychiatrists is critical. This paper reviews existing literature on training of psychiatrists in India, the cultural construction of their professional identities and autobiographical reflections. The results reveal a scarcity of research on how identities, knowledge, and values are constructed, contested, resisted, sustained, and operationalized through practice. This paper hypothesizes that psychiatric training and practice in India continues to operate chiefly in an instrumental fashion and bears a circular relationship between cultural, hierarchical training structures and patient-carer concerns. The absence of interpretative social science training generates a professional identity that predominantly focuses on the patient and his/her social world as the site of pathology. Infrequent and often superfluous critical cultural reflexivity gained through routine clinical practice further alienates professionals from patients, caregivers, and their own social landscapes. This results in a peculiar brand of theory and practice that is skewed toward a narrow understanding of what constitutes suffering. The authors argue that such omissions could be addressed through nuanced ethnographies on the professional development of psychiatrists during postgraduate training, including the political economies of their social institutions and local cultural landscapes. Further research will also help enhance culturally sensitive epistemology and shape locally responsive mental health training programs. This is critical for majority rural Indians who place their trust in State biomedical care.

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.

BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial.

OBJECTIVE: This study's objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences. METHOD: The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians' first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences. RESULTS: Most frequently, clinicians named case-based behavioral simulations as "most helpful" and video as "least helpful" training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician's age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01-1.10; p = 0.025). CONCLUSIONS: Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.

Perspectives of family members participating in cultural assessment of psychiatric disorders: findings from the DSM-5 International Field Trial.

Despite the important roles families play in the lives of many individuals with mental illness across cultures, there is a dearth of data worldwide on how family members perceive the process of cultural assessment as well as to how to best include them. This study addresses this gap in our knowledge through analysis of data collected across six countries as part of a DSM-5 Field Trial of the Cultural Formulation Interview (CFI). At clinician discretion, individuals who accompanied patients to the clinic visit (i.e. patient companions) at the time the CFI was conducted were invited to participate in the cultural assessment and answer questions about their experience. The specific aims of this paper are (1) to describe patterns of participation of patient companions in the CFI across the six countries, and (2) to examine the comparative feasibility, acceptability, and clinical utility of the CFI from companion perspectives through analysis of both quantitative and qualitative data. Among the 321 patient interviews, only 86 (at four of 12 sites) included companions, all of whom were family members or other relatives. The utility, feasibility and acceptability of the CFI were rated favourably by relatives, supported by qualitative analyses of debriefing interviews. Cross-site differences in frequency of accompaniment merit further study.

Mental illness, poverty and stigma in India: a case-control study.

OBJECTIVE: To assess the effect of experienced stigma on depth of multidimensional poverty of persons with severe mental illness (PSMI) in Delhi, India, controlling for gender, age and caste. DESIGN: Matching case (hospital)-control (population) study. SETTING: University Hospital (cases) and National Capital Region (controls), India. PARTICIPANTS: A case-control study was conducted from November 2011 to June 2012. 647 cases diagnosed with schizophrenia or affective disorders were recruited and 647 individuals of same age, sex and location of residence were matched as controls at a ratio of 1:2:1. Individuals who refused consent or provided incomplete interview were excluded. MAIN OUTCOME MEASURES: Higher risk of poverty due to stigma among PSMI. RESULTS: 38.5% of PSMI compared with 22.2% of controls were found poor on six dimensions or more. The difference in multidimensional poverty index was 69% between groups with employment and income of the main contributors. Multidimensional poverty was strongly associated with stigma (OR 2.60, 95% CI 1.27 to 5.31), scheduled castes/scheduled tribes/other backward castes (2.39, 1.39 to 4.08), mental illness (2.07, 1.25 to 3.41) and female gender (1.87, 1.36 to 2.58). A significant interaction between stigma, mental illness and gender or caste indicates female PSMI or PSMI from 'lower castes' were more likely to be poor due to stigma than male controls (p<0.001) or controls from other castes (p<0.001). CONCLUSIONS: Public stigma and multidimensional poverty linked to SMI are pervasive and intertwined. In particular for low caste and women, it is a strong predictor of poverty. Exclusion from employment linked to negative attitudes and lack of income are the highest contributors to multidimensional poverty, increasing the burden for the family. Mental health professionals need to be aware of and address these issues.