Reflections of mental health professionals on working with and in the climate crisis.

The aim of this paper is to share our experiences of engaging with the climate crisis as citizens and mental health professionals (MHPs). We hope the outputs will usefully validate the experiences of fellow MHPs and support them to reflect on their role in this crisis. We came together as eight MHPs, participating in group discussions and one-one interviews with the first author to reflect on our experiences. The collaboratively generated themes reflect how engagement with the crisis has: (i) disrupted our personal and professional experiences; (ii) helped us adapt and grow; and (iii) enabled us to live, work and act in more accordance with our values. A key reflection was that these experiences are not linear and we continue to wrestle with our responses to the climate crisis. Discussions also elicited visions of how mental health paradigms could be better adapted to meeting the escalating public health need that this crisis is generating. We conclude by advocating for MHPs to process and respond to the climate crisis and recognize that their skills can make a vital contribution to this global challenge.

The role of mental health professionals in the climate crisis: an urgent call to action.

The climate and ecological crisis will constitute the defining public health challenge of the twenty-first century, posing an unprecedented global threat to all determinants of health, and to healthcare delivery systems. We believe that mental health professionals have a crucial role to play in responding to this crisis. Whilst responding to the mental health consequences of the climate crisis will remain a key role for us as mental health professionals, we argue that our remit goes beyond this, and should include advancing public understanding of the climate crisis, highlighting its impact on physical and mental wellbeing, and advocating for systemic changes to limit its impending harms. This paper is an urgent call to action for all mental health professionals to take up a role in the context of the climate and ecological crisis. This paper will describe the relationship between mental health and climate change, and frame it within wider systemic and conceptual frameworks. It will demonstrate that as mental health professionals we are well placed to act as leaders of change-arguing that we have a duty to do so-and suggest actions that can be implemented depending on interests, skill sets and opportunities.

A Path for Psychiatry to Thrive.

Exciting changes have the potential to reshape the tools used to treat mental illness, promote mental health, and bring this country's too-long fragmented and specialist-centered mental health system closer to delivering on the goals of improving population health, expanding access, and engaging with structural and social determinants. Innovative practices such as task sharing, cross-sector integration, and participatory methods are ready to be mainstreamed into psychiatric professional identity and practice. Local governments have started to adopt these new strategies, perhaps the most prominent recent example being ThriveNYC, a comprehensive attempt to drive mental health improvement. By enabling and partnering with other practitioners in these ways, psychiatrists can reach more people in more places, giving psychiatry an opportunity to evolve and flourish. As psychiatrists, we and our leadership should seize that opportunity and help lead this progress.

ThriveNYC: Delivering on Mental Health.

Promoting population mental health and meeting the burdens of mental illness is a priority public health challenge of the 21st century. But too little attention has been placed on how to design and sustain the scope of strategies and commitments that credibly live up to the full breadth of that challenge. ThriveNYC is an effort by New York City to fill that gap, through a public health approach backed by investment in resources and leadership. ThriveNYC can by example help mobilize a larger community of investigators and policymakers to consider how to meet this challenge, to get to consensus on key elements for effective action and implementation, to reimagine who and what the mental health "system" includes, and, in doing so, to strengthen the social contract that underlies well-being.

Food insecurity, mental distress and suicidal ideation in rural Africa: Evidence from Nigeria, Uganda and Ghana.

BACKGROUND: In sub-Saharan Africa, mental and substance-related disorders account for 19% of all years lived with disability, yet the intersection between poverty and mental distress is poorly understood since most psychiatric research is conducted in high-income countries. AIMS: To examine the prevalence of and associations between food insecurity, mental distress and suicidal ideation in three rural village clusters in sub-Saharan Africa. METHOD: Cross-sectional multivariate analysis of sociodemographic variables associated with mental distress and suicidal ideation in three countries. The sample included 1,142 individuals from three rural village clusters in Nigeria ( n = 380), Uganda ( n = 380) and Ghana ( n = 382). Food insecurity was measured based on the number of months in the previous year that the respondent's family reported being 'unable to eat two square meals per day'. Mental distress was assessed using the Kessler non-specific psychological distress scale (K6) and suicidal ideation was measured using an item from PRIME-MD. Other sociodemographic variables included gender, age, literacy and occupation. RESULTS: The prevalence of individuals with moderate or severe mental distress in Nigeria, Uganda and Ghana were higher than previously reported in the literature: 35.5%, 30.8% and 30.4%, respectively, and suicidal ideation rates were 29.7%, 21.3% and 10.9%. No differences were observed in mental distress between men and women in any of the sites. Being a farmer (vs student or other) was protective for mental distress in two sites (Uganda and Ghana) but no other social indicators, such as age, gender, literacy and food insecurity, were significantly associated with mental distress. Risk for suicidal ideation differed across sites: it was associated with food insecurity in Nigeria, female gender in Uganda, and older age in Uganda. CONCLUSIONS: Mental distress and suicidal ideation were highly prevalent in three settings of extreme poverty across all groups, in ways that were not always consistent with the global literature. These findings suggest that more research is needed in to better understand the social etiology of mental distress in sub-Saharan Africa.

A Path Not Taken: Beecher, Brain Death, and the Aims of Medicine.

It has been fifty years since a report by an ad hoc committee of Harvard Medical School ushered in the widespread adoption of brain death as a definition of death. Yet brain death remains disputed as an acceptable definition within bioethics. The continuous debate among bioethicists has had three key recurring features: first and foremost, argument over alleged flaws in the conceptual logic and consistency of the "whole-brain" approach as a description of the meaning of death; second, efforts to fix perceived limitations of brain death-based practices to optimize transplantation, especially given that transplantation was the presumed original intended purpose of the definition; and third, a basic unease provoked by the experience of using the criteria and managing a body in this state of "irreversible coma." The third feature is the one I find the most compelling, though it is less explored, and it persists because of the failures of the prior two. Brain death remains strange-to medical personnel, families, philosophers. That is not because it hasn't yet been logically argued well enough or conceptually framed adequately, but because those things don't matter as much to resolving this strangeness as the bioethical approach to brain death over the last fifty years has assumed it does. It is necessary to look to other things that can anchor the aims of medicine in the midst of this strangeness.

The cost-effectiveness of PHQ screening and collaborative care for depression in New York City.

BACKGROUND: Depression is under-diagnosed and under-treated in most areas of the US. New York City is currently looking to close gaps in identifying and treating depression through the adoption of a screening and collaborative care model deployed throughout the city. METHODS: We examine the cost-effectiveness of universal two-stage screening with the 2- and 9-item Patient Health Questionnaires (PHQ-2 and PHQ-9) in New York City followed by collaborative care for those who screen positive. We conducted microsimulations on hypothetical adult participants between ages 20 and 70. RESULTS: The incremental cost-effectiveness of the interventions over the average lifespan of a 20-year-old adult in NYC is approximately $1,726/QALY gained (95% plausible interval: cost-saving, $10,594/QALY gained). CONCLUSIONS: Two-stage screening coupled with collaborative care for depression in the clinical setting appears to be significantly less expensive than most clinical preventive interventions, such as HIV screening in high-risk patients. However, effectiveness is dependent on the city's ability to manage scale up of collaborative care models.

Development and validation of a Haitian Creole screening instrument for depression.

Developing mental health care capacity in postearthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current paper describes a novel emic-etic approach to developing a depression screening for Partners in Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.

Measuring depression and anxiety in sub-saharan Africa.

BACKGROUND: Despite being one of the leading causes of disability worldwide, fewer than 10% of depressed individuals in low-resource settings have access to treatment. Mounting evidence suggests that nonspecialist workers are capable of providing counseling and case management at the community level. They often use brief psychiatric screening instruments as clinical tools to identify cases and monitor symptoms over time. In order for such tools to be used in diverse settings, they must demonstrate adequate reliability and validity in addition to cross-cultural relevance. To be used to guide routine care they also need to be flexibly adapted and sensitive to change. The goal of this paper is to assess the cross-cultural validity of brief psychiatric screening instruments in sub-Saharan Africa, identify best practices, and discuss implications for clinical management and scale-up of mental health treatment in resource-poor settings. METHOD: Systematic review of studies assessing the validity of screening instruments for depression, anxiety, and mental distress in sub-Saharan Africa using Medline and PsycINFO. RESULTS: Sixty-five studies from 16 countries assessing the validity of brief screening instruments for depression, anxiety, and/or mental distress. CONCLUSIONS: Despite evidence of underlying universality in the experience of depression and anxiety in sub-Saharan Africa, differences in the salience, manifestation, and expression of symptoms suggest the need for the local adaptation of instruments. Rapid ethnographic assessment has emerged as a promising, low-cost, and efficient strategy for doing so.

The 2010 Haiti earthquake response.

This article presents an overview of the mental health response to the 2010 Haiti earthquake. Discussion includes consideration of complexities that relate to emergency response, mental health and psychosocial response in disasters, long-term planning of systems of care, and the development of safe, effective, and culturally sound mental health services in the Haitian context. This information will be of value to mental health professionals and policy specialists interested in mental health in Haiti, and in the delivery of mental health services in particularly resource-limited contexts in the setting of disasters.

Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions.

Significant challenges exist in providing safe, effective, and culturally sound mental health and psychosocial services when an unforeseen disaster strikes in a low-resource setting. We present here a case study describing the experience of a transnational team in expanding mental health and psychosocial services delivered by two health care organizations, one local (Zanmi Lasante) and one international (Partners in Health), acting collaboratively as part of the emergency response to the 2010 Haiti earthquake. In the year and a half following the earthquake, Zanmi Lasante and Partners in Health provided 20,000 documented individual and group appointments for mental health and psychosocial needs. During the delivery of disaster response services, the collaboration led to the development of a model to guide the expansion and scaling up of community-based mental health services in the Zanmi Lasante health care system over the long-term, with potential for broader scale-up in Haiti. This model identifies key skill packages and implementation rules for developing evidence-based pathways and algorithms for treating common mental disorders. Throughout the collaboration, efforts were made to coordinate planning with multiple organizations interested in supporting the development of mental health programs following the disaster, including national governmental bodies, nongovernmental organizations, universities, foreign academic medical centers, and corporations. The collaborative interventions are framed here in terms of four overarching categories of action: direct service delivery, research, training, and advocacy. This case study exemplifies the role of psychiatrists working in low-resource settings as public health program implementers and as members of multidisciplinary teams.

Teaching "global mental health": psychiatry residency directors' attitudes and practices regarding international opportunities for psychiatry residents.

OBJECTIVE: The authors surveyed Psychiatry Residency Training Directors' (RTDs') attitudes about the role and feasibility of international rotations during residency training. METHOD: A 21-question survey was electronically distributed that explored RTDs' beliefs about the value, use, and availability of international clinical and research experiences during residency. RESULTS: Of 171 RTDs, 59 (34.5%) completed the survey; 83% of respondents rated the importance of global mental health education as 3-or-above on a scale of 1 (least important) to 5 (most important), but only 42% indicated that such opportunities were made available. The value of such opportunities was thought to lie primarily in professional development and cultural exposure, less so for enhancing core knowledge competencies. Obstacles to such opportunities included lack of accreditation, financial resources, and faculty/administrative support and supervision. CONCLUSION: RTD respondents endorsed the value of international experiences during residency, but their availability and educational impact are not fully supported.

Scaling up for the "bottom billion": "5 x 5" implementation of community mental health care in low-income regions.

Common mental disorders pose tremendous health and social burdens in the poorest countries. This Open Forum describes a planning framework to advance effective, sustainable design and implementation of mental health services in these settings. It builds on research in treatment dissemination and on the authors' experience in several initiatives-including the Millennium Villages Project in sub-Saharan Africa and the Partners In Health system in Haiti (Zanmi Lasante). The authors describe a "pyramid of care" approach that specifies five key skill packages to address common mental disorders in low-resource settings and five implementation rules: assess context first; identify priority care pathways and map them across skill packages; specify decision supports, supervision, and triage rules; use quality improvement practices; and plan for sustainability and capacity building. The framework addresses the need for a shared vocabulary and a set of tools to coordinate and compare efforts to scale-up mental health treatment across diverse settings.

Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services- improving patient-centered care.

The reduction of seclusion and restraint (S/R) use has been given national priority by the US government, The Joint Commission, and patient advocacy groups. It is associated with high rates of patient and staff injuries and is a coercive and potentially traumatizing intervention. The New York City Health and Hospitals Corporation (HHC) is the largest municipal health care system in the country, with 11 HHC facilities operating psychiatric emergency services and inpatient psychiatric services. HHC operates 1117 adult inpatient psychiatric beds with an average length of stay of 22.2 days that generated over 19,000 discharges in 2009. In 2009, there were over 36,000 psychiatric emergency services visits. HHC's Office of Behavioral Health provides strategic leadership, planning, and support for the operations and quality objectives of these services. In January 2007, the corporate office initiated the Seclusion and Restraint Reduction Initiative, with a sequenced, intensive series of interventions and strategies to help focus the behavioral health leadership and staff on the need for continued culture change toward a more patient-centered and safe system of psychiatric emergency and adult inpatient care. From 2007 to 2009, there was a substantial decline in HHC's overall rate of S/R incidents in inpatient units. The more substantial impact was in the reduced overall time spent in S/R; the reduced frequency of use of S/R; and the reduced likelihood of patient injury from S/R use.

Mental health and the development agenda in Sub-Saharan Africa.

This article synthesizes the views of participants in two roundtables that were convened in Nairobi (March 2007) and London (July 2008) to identify key challenges to the prioritization of mental health in Africa and possible solutions. Participants included leading development experts and policy makers from head and country offices of international donors, national directors of mental health for several African countries, key mental health and public health professionals, epidemiologists, and an international nongovernmental organization. The challenges they identified to mainstreaming mental health include lack of understanding of the contribution of mental disorders to morbidity and mortality, competition for limited resources within health reform efforts, poor distribution of interventions and lack of inclusion of mental health among core generic health indicators, lack of economic research evidence, lack of a strategic approach to human resources planning, lack of partnerships with the social development sector, and mental health professionals' need for public health skills to effectively conduct national advocacy. Potential solutions include further investment in economic research, better strategic identification of the levers and entry points for integrating mental health into health sector reform plans, more vigorous engagement of mental health professionals in general health sector reforms, strengthening the linkage between mental health and social development, and intensive resource mobilization. In summary, partnerships, underpinned by collaborative training, research, and mutual dialogue with other health and nonhealth sectors, are needed.