Stigma towards mental illness in Asian nations and low-and-middle-income countries, and comparison with high-income countries: A literature review and practice implications.

Background: Stigma related to mental illness (and its treatment) is prevalent worldwide. This stigma could be at the structural or organizational level, societal level (interpersonal stigma), and the individual level (internalized stigma). Vulnerable populations, for example, gender minorities, children, adolescents, and geriatric populations, are more prone to stigma. The magnitude of stigma and its negative influence is determined by socio-cultural factors and macro (mental health policies, programs) or micro-level factors (societal views, health sectors, or individuals' attitudes towards mentally ill persons). Mental health stigma is associated with more serious psychological problems among the victims, reduced access to mental health care, poor adherence to treatment, and unfavorable outcomes. Although various nationwide and well-established anti-stigma interventions/campaigns exist in high-income countries (HICs) with favorable outcomes, a comprehensive synthesis of literature from the Low- and Middle-Income Countries (LMICs), more so from the Asian continent is lacking. The lack of such literature impedes growth in stigma-related research, including developing anti-stigma interventions. Aim: To synthesize the available mental health stigma literature from Asia and LMICs and compare them on the mental health stigma, anti-stigma interventions, and the effectiveness of such interventions from HICs. Materials and Methods: PubMed and Google Scholar databases were screened using the following search terms: stigma, prejudice, discrimination, stereotype, perceived stigma, associate stigma (for Stigma), mental health, mental illness, mental disorder psychiatric* (for mental health), and low-and-middle-income countries, LMICs, High-income countries, and Asia, South Asian Association for Regional Cooperation/SAARC (for countries of interest). Bibliographic and grey literature were also performed to obtain the relevant records. Results: The anti-stigma interventions in Asia nations and LMICs are generalized (vs. disorder specific), population-based (vs. specific groups, such as patients, caregivers, and health professionals), mostly educative (vs. contact-based or attitude and behavioral-based programs), and lacking in long-term effectiveness data. Government, international/national bodies, professional organizations, and mental health professionals can play a crucial in addressing mental health stigma. Conclusion: There is a need for a multi-modal intervention and multi-sectoral coordination to mitigate the mental health stigma. Greater research (nationwide surveys, cultural determinants of stigma, culture-specific anti-stigma interventions) in this area is required.

Moving from serotonin to serotonin-norepinephrine enhancement with increasing venlafaxine dose: clinical implications and strategies for a successful outcome in major depressive disorder.

INTRODUCTION: Mental health disorders, especially depressive and anxiety disorders, are associated with substantial health-related burden. While the second-generation antidepressants are widely accepted as first-line pharmacological treatment for major depressive disorder (MDD), patient response to such treatment is variable, with more than half failing to achieve complete remission, and residual symptoms are frequently present. AREAS COVERED: Here, the pharmacodynamics of venlafaxine XR are reviewed in relation to its role as both a selective serotonin reuptake inhibitor (SSRI) and a serotonin-norepinephrine-reuptake inhibitor (SNRI), and we look at how these pharmacodynamic properties can be harnessed to guide clinical practice, asking the question 'is it possible to develop a symptom-cluster-based approach to the treatment of MDD with comorbid anxiety utilizing venlafaxine XR?.' Additionally, three illustrative clinical cases provide practical examples of the utility of venlafaxine-XR in real-world clinical practice. The place of venlafaxine XR in managing fatigue/low energy, a frequent residual symptom in MDD, is explored using pooled data from clinical trials of venlafaxine XR. EXPERT OPINION: Venlafaxine XR should be considered as a first-line treatment for MDD with or without comorbid anxiety, and there are clear pharmacodynamic signals supporting a symptom cluster-based treatment paradigm for venlafaxine XR.

Latin American consensus recommendations for the management and treatment of patients with treatment-resistant depression (TRD).

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD, and available treatment pathways for the management of TRD vary across the Latin American region, highlighting the need for a uniform definition and treatment principles to optimize the management of TRD in Latin America. METHODS: Following a thematic literature review and pre-meeting survey, a Latin America expert panel comprising 14 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA appropriateness method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management. RESULTS: The expert panel agreed that 'treatment-resistant depression' (TRD) is defined as 'failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode'. A stepwise treatment approach should be employed for the management of TRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Nonpharmacological treatments, such as electroconvulsive therapy, are also appropriate options for patients with TRD. CONCLUSION: These consensus recommendations on the operational definition of TRD and approved treatments for its management can be adapted to local contexts in the Latin American countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with TRD.

Reducing the stigma of mental health disorders with a focus on low- and middle-income countries.

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.

Solutions to prevent and address physician burnout during the pandemic in Mexico.

BACKGROUND: The COVID-19 pandemic has tested the level of preparedness and readiness of governments globally. The demand for services exceeding the capacity of the health systems in both developed and developing countries has been the rule rather than the exception. Physicians and the rest of the health-care personnel have been put through unprecedented levels of demand, within a field of uncertainty, from an evolving and insufficient understanding of the pathophysiology of the viral process, the unclear benefit of face coverings used by the general public, numerous pharmacological candidates, insufficient personal protection equipment, and the highly expected vaccine. AIMS AND OBJECTIVES: Design a program to address the emotional and psychiatric needs of COVID-19 first response Healthcare personnel in Mexico. MATERIALS: in march 2020, the Mexican Psychiatric Association was invited to be part of the Workgroup for the fortification of Mental Health during Disasters of the Ministry of Health in Mexico. The charge was to develop a program to address the needs and prevent burn out in physicians and the rest of healthcare personal. The details of how this program was planned, implemented, and launched will be presented. RESULTS: The program was launched in two phases. Phase A through a chat with text messaging capability was launched on 25 April, 2020. B through telepsychiatric video calls, was launched on 15 June, 2020. Phase A had a very limited demand. Phase B also had a very limited demand until the month 5 September, 2020. CONCLUSIONS: from the time of program launch through the first four months, the demand was very low, what may be explained due to "normalization" of stress and/or stigma among healthcare professionals. Our personnel deserve the utmost support from their society.

Mental health in the age of COVID-19, a Mexican experience.

As of June 2020 the number of Coronavirus cases in Canada, Mexico, Central America and the Caribbean are just under 2.5 million infections and over 140,000 deaths. The health systems in half of the countries in the Americas and the rest of the world have faced the pandemic positioned from different perspectives. While Canada and the United States already had extensive experience in the practice of telemedicine, other countries such as Mexico and the Caribbean, doctors from both private and public sectors have been forced to start practicing medicine remotely. As a result there have been limitations such as poor access to technology, lack of privacy legislation, and difficulties with fee collection among many others. These situations must be taken in account to understand what is happening in the region. On the other hand, the need to continue providing medical attention is indisputable. We understand that COVID 19 besides other systems damages the CNS, patients present severe neuropsychiatric symptoms that range from headache, anosmia, ageusia, confusional state alteration of consciousness, toxic metabolic encephalopathies, encephalitis, seizures, cerebral vascular events, Guillan Barre-type demyelinating neuropathies, to the extent of conditions such as anxiety, acute stress disorder, post-traumatic stress disorder, depression, and eventually psychotic episodes. As time passes we try to differentiate the origin of the symptoms. We will learn which of these symptoms are a result of metabolic complications, which others are due to drug's secondary effects and which ones are adaptive response. Therefor our contribution to the editorial supplements is given in two lines of analysis: disease physiopathology and ways to deliver treatment to the population.

Mental Health Attribution for Mexican-Origin Latinx and Non-Latinx Older Adults: A Latent Class Analysis.

BACKGROUND AND OBJECTIVES: Providing appropriate and culturally sensitive care to the rapidly growing number of U.S. Latinx older adults with psychiatric conditions presents a major public health challenge. We know little about older Latinx adults' perceived causes of mental health problems, offering clinicians limited insight to guide successful and culturally congruent treatment. Moreover, there is a paucity of mental health research examining heterogeneity in how Latinx individuals may attribute mental health symptoms. The present study sought to identify how Latinx and non-Latinx older adults attributed the sources of their mental health problems and how these types of attributions differ by ethnicity. RESEARCH DESIGN AND METHODS: This study analyzed data collected from a retrospective chart review and survey of 673 adults aged 55-95 years (430 Mexican origin and 244 non-Latinx) from a rural psychiatric outpatient clinic near the California-Mexico border. We conducted stratified latent class analysis (LCA) by race/ethnicity to explore the mental health attribution beliefs of Mexican-origin and non-Latinx clinic patients. RESULTS: Different LCA patterns for Mexican-origin Latinx versus non-Latinx groups were found. For non-Latinx adults, there was a class of individuals who attributed their mental health issues to social and financial problems. For Mexican-origin adults, there was a class of individuals who attributed their mental health issues to spiritual and/or supernatural factors, unaffected by acculturation level, depressive symptom severity, and time spent in the United States, but differing by gender. We found within-group heterogeneity: Not all Mexican-origin or non-Latinx older adults were alike in how they conceptualized their mental health. DISCUSSION AND IMPLICATIONS: Mexican-origin Latinx and non-Latinx older adults attributed their mental health issues to different causes. More Mexican-origin older adults attributed their symptoms to spiritual causes, even after controlling for contextual factors. Further research is needed to determine whether attribution beliefs are affected by specific mental health diagnoses and other cultural factors not measured in this study.

Differences in BMI between Mexican and Colombian patients receiving antipsychotics: results from the International Study of Latinos on Antipsychotics (ISLA).

Objective: The objective of this study is to examine the association of country of residence with body mass index (BMI) between Mexican and Colombian patients exposed to antipsychotics. We hypothesize that there will be a significant association between country of residence and BMI and that Mexican patients will have higher BMI than their Colombian counterparts.Design: The International Study of Latinos on Antipsychotics (ISLA) is a multisite, international, cross sectional study of adult Latino patients exposed to antipsychotics in two Latin American Countries (i.e. Mexico and Colombia). Data were collected from a total of 205 patients (149 from Mexico and 56 from Colombia). The sites in Mexico included outpatient clinics in Mexicali, Monterrey and Tijuana. In Colombia, data were collected from outpatient clinics in Bogotá. For this study we included patients attending outpatient psychiatric community clinics that received at least one antipsychotic (new and old generation) for the last 3 months. A linear regression model was used to determine the association of country of residence with BMI for participants exposed to an antipsychotic.Results: After controlling for demographics, behaviors, biological and comorbid psychiatric variables, there was a significant difference between Colombia vs. Mexico in the BMI of patients exposed to antipsychotics (ß = 4.9; p < 0.05).Conclusion: Our hypotheses were supported. These results suggest that differences in BMI in patients exposed to antipsychotics in Mexico and Colombia may reflect differences in prevalence of overweight/obesity at the population level in the respective countries, and highlights the involvement of other risk factors, which may include genetics.

Telephone-assisted, parent-mediated CBT for rural Latino youth with anxiety: A feasibility trial.

OBJECTIVE: In this study, we tailor a child anxiety cognitive-behavior therapy (CBT) program to fit the needs of rural Latino/a Spanish-speaking families and examine the feasibility, acceptability, tolerability, and safety of this intervention using 2 modes of service delivery. METHOD: Children (n = 31; age 8-13) with anxiety disorders were recruited from primary care settings and randomized to 1 of 2 modes of parent-mediated CBT bibliotherapy: (1) telephone-delivered, therapist-assisted bibliotherapy (TTB; n = 15), and (2) a more minimal contact, self-directed, bibliotherapy condition (SB; n = 16). Independent evaluators administered a diagnostic interview at baseline and posttreatment; demographic and engagement-related questionnaires were also administered. RESULTS: In the TTB group, 10 of 15 parents (66.7%) completed the requisite number of therapist-assisted bibliotherapy sessions, and in the SB group, 4 of 16 parents (25%) completed the requisite number of self-directed bibliotherapy modules; this comparison was significant, χ2(1) = 5.43, p = .02. In the TTB condition, treatment length and session duration were longer than reported in previous studies. Barriers that were most strongly endorsed were stressors and obstacles competing with treatment, as well as treatment demandingness. Findings revealed good satisfaction across the conditions, although ratings were significantly higher in the TTB group, F = 5.67, p = .028. Remission rates (i.e., no anxiety disorder) for those that provided posttreatment data (N = 25) were 50% and 36% for the TTB and SB groups, respectively, χ2(1) = .465, p = .50. CONCLUSIONS: Implications of these feasibility findings and suggestions for future research are discussed. (clinicaltrials.gov unique identifier: NCT01491880). (PsycINFO Database Record

Delivering CBT to Rural Latino Children with Anxiety Disorders: A Qualitative Study.

Qualitative methods were used to understand community perspectives about ways to deliver cognitive behavior therapy (CBT) to rural Latino youth with anxiety. First, four focus groups were conducted with 28 bilingual Latino mental health providers to examine perceptions of CBT using telephone based, therapist supported bibliotherapy, and bibliotherapy without therapist support. Second, qualitative interviews were conducted with 15 Latino parents from a rural community to better understand attitudes toward CBT, and modes of service delivery. Qualitative findings revealed that parents were mostly positive about psychotherapy, and the core elements of CBT for anxiety. However, both parents and providers emphasized the need for adaptations to address practical and perceived barriers to treatment, such as time, convenience, homework, and literacy. Many parents spoke favorably of a telephone-based approach that could address many of their perceived barriers, while providers were expressed more negative views. Such findings are important for data-driven treatment development efforts.

Telepsychiatry for Neurocognitive Testing in Older Rural Latino Adults.

As the population of older Latinos in the U.S. increases, availability of culturally adapted geriatric psychiatry services is becoming a growing concern. This issue is exacerbated for rural Latino populations. In this study, we assessed whether neurocognitive assessment via telepsychiatry (TP) using a Spanish-language battery would be comparable to in-person (IP) testing using the same battery in a sample of Spanish-speaking older adults in a rural setting. Patients (N = 22) received IP and TP testing 2 weeks apart. The order of IP and TP test administrations in individual subjects was determined randomly. Comparison of scores indicated that there were no significant differences between IP and TP test performance though both groups scored non-significantly higher at the second visit. This study demonstrates feasibility and utility of neurocognitive testing in Spanish using TP among older rural Latinos.

Anxiety disorders and rapid cycling: data from a cohort of 8129 youths with bipolar disorder.

Anxiety disorders (ADs) are common in youths with bipolar disorder (BD). We examine psychiatric comorbidity, hospitalization, and treatment in youths with versus without AD and rapid cycling (four or more cycles per year). Data from the Integrated Healthcare Information Services cohort were used and included 8129 youths (ages ≤18 years). Prevalence of AD, demographic, type of AD, hospitalization, and use of psychotropics were compared between rapid and nonrapid cycling. Overall, 51% of the youths met criteria for at least one comorbid AD; they were predominantly female and were between 12 and 17 years of age. The most common comorbid ADs were generalized ADs and separation ADs. In the patients with rapid cycling, 65.5% met criteria for comorbid AD. The BD youths with AD were more likely to have major depressive disorders and other comorbid ADs, to be given more psychotropics, and to be hospitalized for depression and medical conditions more often than were those without AD.

To what factors do rural-dwelling hispanics attribute depressive symptoms?

This study is a retrospective chart review comparing rural-dwelling Caucasian and Hispanic outpatients' attribution of depressive symptoms. Based on the data gathered at intake, Hispanics were more likely to attribute depression to curse/spell and supernatural causes, while Caucasians were more likely to attribute symptoms to hereditary factors or job stress. Among both groups, higher CESD score was associated with problems with significant others or how they got along with others. Among Hispanics, depression severity was additionally associated with problems related to job or finances. Our findings point to a consequential role for clinical inquiry into attributed causes of depressive symptoms.