Psychosis, 2016

2010

The second half of the 20 th century has witnessed major changes in the way mental health care in the Western countries has been organized and provided for people suffering from mental illness. Deinstitutionalization and community care became common terms used to define a policy that aims to shift the locus of psychiatric care from large mental hospitals and custodial institutions into community. Deinstitutionalization of psychiatric care requires an empowering approach towards the mentally ill individuals and their capabilities to lead a self-dependent life in the community. Such an approach implies accepting the mentally ill health-care service users as credible individuals capable of taking responsibility for their actions and life. The aim of this article is to examine psychiatric conception of mental illness, treatment and the psychiatric encounter. The presentation largely draws upon analysis of Lithuanian psychiatric texts, although some foreign psychiatric literature is also used. The article starts with an introduction of a changing situation of the mental patient and proceeds to the analysis of the psychiatric discourse. The author argues that by conceptualizing mental illness as pathology located within the functioning of the individual body that affects the ability of a sick individual to apprehend the reality and to retain critical insight towards one's health problem, psychiatric discourse may reproduce paternalistic approach towards the mentally ill individuals even in the deinstitutionalized settings. Such an approach may have certain implications for the individuals' ability to lead an independent life in the community.

2019

Background: Since 1999 the Romanian health insurance system shifts to aBismarckmodel where primary care is provided by family medicine physicians, in private practices, under contract with local insurance houses. Family doctors are supposed to have a Gatekeeping role, ensuring that patients see specialists only for conditions that could not be managed at this level and are referred to an appropriate specialist. Aims: To explore the opinions of the family doctors on the interventions needed for a better management of the psychiatric cases. Method: A survey was conducted among 43 family doctors fromGalaticounty (Romania). Results and Discussion: Despite a formal gatekeeping role, Romanian family doctors do not have a pivotal role in coordinating psychiatric care. Direct access to a specialist is possible for certain pathologies and there is evidence of overuse of ambulance services, hospital services and outpatient care setting bypassing primary care. Conclusion: Rather than focusing...

We live in a world that is increasingly complex, intense, and stressful. Most people, at some time or other in their lives, can make good use of psychiatry as they map their course and steer their way through it. While this holds true, there also exists a very disturbing trend. No other branch of medicine suffers a similar, constant criticism, scrutiny and quite often downright vehement protest. Even the service users, who have been greatly benefitted, choose to stay mum for fear of stigmatization that may follow if they admit to have undergone therapy.

2013

Increasing division of specialisation in modern medicine has specifically unwrapped the issues of challenges of mental health. This article highlights the importance of primary care mental health, problems of awareness and under detection. Finally, challenges in the current status of mental health are highlighted.

Abstract We went to three traditional healers. The first asked one hundred thousand shillings and a goat which we paid but there was no improvement in the patient’s situation. Then they directed us to another traditional healer who told us to pay two hundred thousand shillings which we paid but still there was no change. It was the third traditional healer who told us that the illness was not folk and advised us to bring the patient to the hospital. Culture influences people’s health seeking behavior, response to stress in one’s daily life and adherence to therapeutic measures. There is a need to take culture into account in order to make valid diagnostic categorizations and to understand the patient’s expression to ill-health (Baarnhielm, 2012). Culture plays a very important role in the way people experience the phenomenon of illness. The aetiology or cause of mental distress in non- western cultures is always explained in symbolic formulations depending on one’s culture. In most cultures in Africa, aetiology is either witchcraft or sorcery from ones social, economic or political enemies (Evans-Prichard, 1937; Rivers, 1924; Glick, 1998; Wellin, 1998). It can also be some unhappy ancestral spirits or due to breach of a taboo (Rivers, 1924). To manage mental illnesses, one has to perform traditional rituals which involve animal sacrifices as observed by some of the patients and caregivers interviewed. Such illnesses can be prevented by avoiding; creating social enemies and breaking taboos. Such explanations of aetiology and effective management and preventive measures of mental illnesses show how cultures frame the phenomenology and psychopathology of mental illnesses. However, the prevalence of mental illnesses among people is also influenced by social, economic and political factors which affect mental health directly or indirectly. Proper diagnosis and treatment of mental illnesses should put into consideration all these factors in order to achieve positive mental health. Key Words: Mental illnesses, Management, Caregiver, patient

Revista Brasileira de Medicina de Família e Comunidade

Na Sétima Cúpula Ibero-Americana de Medicina Familiar, Cali – Colombia 2018, o grupo de trabalho Saúde Mental (SM) refletiu sobre como a Medicina de Família (MF) pode atuar em para apoiar a saúde integral das pessoas que enfrentam situações de estresse na vida diaria, como conflitos armados/desarmados, emergências e desastres naturais. Estudo descritivo transversal com base em um levantamento de 42 perguntas a 99 profissionais de saúde ibero-americanos provenientes de 15 países; 98 médicos e 1 psicólogo. 8% de residentes de MF, 85% de especialistas em MF, 4% de clínicos gerais, 2% de psiquiatras e 1% de internistas. 47% dos médicos percebem como boa a capacidade dos médicos de família na abordagem da SM. Em relação aos problemas SM, 30% indicam Transtorno de Ansiedade, 27% de depressão, 17% de insônia, 10% de alcoolismo, 7% de dependência de drogas ilícitas, 5% de transtornos alimentares e 4% de transtorno de estresse pós-traumático. Neste contexto, foram feitas recomendações para a...

Culture, Medicine, and Psychiatry

What the father is silent comes out in the mouth of the son, and I have often found that the son was the father's revealed secret." Friedrich Nietzsche "What is silent in the first generation, the second generation carries in the body." Françoise Dolto Based on these two quotations, one from a philosopher and the other from a pediatrician and psychoanalyst, we are going to start this reflection about the look, posture and practice of the alternative therapeutic approach of Family Constellations in relation to psychoses. The questions that guided this reflection were: Would it be possible to work with psychotic conditions based on Family Constellations? What are the possibilities and consequences of an alternative therapeutic approach to act on conditions as complex and delicate as that of psychoses? Could we use this technique as an alternative for conflict resolution, mainly because we are talking about conflicts that go beyond generations and involve the family, ancestral system as a whole? This author's interest in working therapeutically with psychoses began in 1998, when the first contact with psychotic clients was made in private and public psychiatric institutions. It began by working with inpatient psychiatric patients. The clientele presented intense psychic suffering and the treatments were long and marked by several relapses. The teams responsible for the treatments were multidisciplinary, involving psychiatry, psychology, occupational therapy, nursing, physical education, therapeutic companions, family therapists, music therapists, art therapists, among others. Inside the psychiatric hospital, in addition to learning from the clientele the clinical listening of suffering and dealing with the extreme situations present in this environment, I was able to verify the necessary steps for rehabilitation and social reintegration offered by therapeutic monitoring and family therapy centers. Psychiatry and nursing were essential for emergency containment, support, relief, treatment and psychopharmacological follow-up. Psychology and occupational therapy worked with therapeutic groups to manifest and elaborate themes and difficulties presented by patients in their sociocultural environment. As the patient improved in his general condition, reintegration into his social and family environment was worked on. Often, at this moment, we noticed a worsening of the staff and resistance from the family structure. Individual psychotherapy, family therapy sessions and therapeutic follow-up came into play. Many patients pointed out that the improvement obtained in the so-called "safe environment" of the institution, of the therapeutic groups and of the individual attendances was put to the test when they returned to their homes, to the social and family life. They realized they were regressing and often expressed sadness and hopelessness: "there's no way, I'm going to be stuck in here forever" (sic).

The Lancet Psychiatry, 2017

To answer these questions, the World Psychiatric Association and The Lancet Psychiatry have commissioned a team of mental health professionals, researchers, and service users to write and review this new Commission on the Future of Psychiatry. The following pages are intended to stimulate thought, debate, and the change necessary for psychiatry to fulfil its potential as an innovative, effective, and inclusive medical specialty in the 21st century. Part 1: The Patient and Treatment Demographic and societal factors affecting the Patient The future of the psychiatric patient in the health care system will be influenced by many factors, several of which will be discussed in other sections of this report. One of the most critically important variables is the availability of and access to psychiatric care. WHO data 1 show vast discrepancies in resources across countries, with, for example, nearly 100-times variations in the per capita availability of psychiatrists. 2 Within specific countries, substantial geographic variations occur in availability of mental health clinicians and facilities as well as in specific treatment modalities such as pharmacological, psychotherapeutic or psychosocial interventions, or neuromodulation therapies. In the USA, with over 50,000 psychiatrists, the highest per capita ratio in the world, and an extensive array of government and privately supported programmes, many subpopulations have inadequate access to any aspects of clinical mental health care including medications. Owing to significant fragmentation compared with the general health system, access is constrained for those living in rural areas and poverty stricken urban cores, and the elderly, children, the homeless, victims of abuse, those in forensic facilities, and members of minority racial and ethnic groups. 3 Thus, it is uncertain whether many of the projections in this section concerning patient care changes in the coming decade will be available to the majority of the global population. While there is no evidence that the epidemiology of most psychiatric disorders is changing, largescale demographic and societal changes already underway will affect individual and population mental health. These are illustrated by four such changes, already occurring in Asia and major population centres elsewhere. First, ageing of the global population will continue due to improved nutrition and water supplies as well as advances in general medical care. 4 The growth in the elderly population means an increase in age-related diseases such as the dementias and late-life depression. Changes in social patterns, with multiple generations of families no longer living in the same houses or even towns, will alter the role of the elderly in the community and the way they are valued and cared for. The increased demands for caregiving by younger family members for the older generations will be less likely served when those younger generations live far away. These changes impair the quality of life of the elderly and can lead to poor mental health outcomes. 5 Moreover, the high prevalence of coexisting physical conditions, such as sensory loss, will exert a greater effect on mental health through the loss of self-esteem and independence. Second, an increasing percentage of the world's population will be living in urban areas. Urbanization affects mental health through the influence of increased stressors and factors such as an overcrowded and polluted environment, high levels of violence, access to illicit drugs, and reduced social support. 6 For example, lower paid urban workers often live in crowded spaces with poor basic sanitation, food supplies, and shelter, as well as a lack of basic governmental and social support services. Third, population disruption and migration due to natural and manmade disasters, are at the highest level in recorded history, 7 with associated adverse effects on mental health. 8 The stresses of forced emigration, physical, social, and psychological, have taxed all societal systems. 9 These stresses stem not only from factors directly related to migration or living in refugee camps, but also from living under the authority of individuals with, most often, a different culture, language, and traditions. Fourth, the rapidly expanding use of electronic communications in our "digital" world has led to concerns about the effect of more constant digital connectivity on individuals, such as a shorter attention span, interpersonal relationships, and society (see section on Psychiatry and the Digital World). Internet Addiction Disorder, while not listed in DSM-5, is of increasing concern in adolescents and young adults. There is a strong association between Internet Addiction Disorder and depression 10 though the causal relationship has not been determined. Culture and Patient Care Culture and Diagnosis With the vast migration of populations in recent decades, attention to cultural factors in understanding mental processes for both individuals and groups, and in psychiatric practice will continue to grow in importance. Diagnosis will continue to be among the most complex issues in psychiatry and will have to take increasing notice of the influence of culture. 11 Cultural variations must be taken into account in the clinician's understanding of the context and meaning of the language of patients, and this appreciation must be a basic component of every diagnostic interpretation. Understanding what patients are communicating to the clinician requires an awareness of the impact of the "cultural relativism" of language and other variables and will produce more effective decision making about normality and psychopathology. 12 The migration of human populations has modified local and regional cultures, but culture continues to be influenced by a multiplicity of factors, and global cultural diversity will persist. Assessment of race and ethnicity, language (verbal and non-verbal), religious beliefs, traditions, values and moral thought, family and gender issues, social relations, financial philosophies, and economic status will continue to be key elements to consider when formulating a diagnosis. 13 These and other cultural variables affect areas such as help-seeking patterns, causal attributions, explanatory models of illness, and severity assessment. The cultural elements inserted in several sections of DSM-5 are only the initial step in a conceptual and practical consolidation of culture in the diagnostic process. 14 The study of Idioms of Distress and Cultural Syndromes in various diagnostic schemes should continue to be refined and implemented in a way that can be used more effectively around the world. 15 DSM-5 developed the Cultural Formulation Interview as a novel 16-question measurement instrument of cultural diagnostic components to be used during an initial interview. This was field tested for utility, and is supported by 12 supplementary modules to broaden and deepen the collected data. 16 Thus, the Cultural Formulation Interview can serve as a platform for further development. Culture and the therapeutic alliance Understood as the common and shared effort of physician and patient aimed at the alleviation, healing or cure of ailments, the therapeutic alliance entails knowledge, attitudes and skills that, if appropriately used, will result not only in the stated objectives but also in the prevention of relapses, and the accomplishment of a better quality of life for the individual and the community. The therapeutic alliance is moderated by both the knowledge base and skills of the clinician, and the influence of culture on the system of care, and the cultural background of the physician and the patient. There is increasing attention to the role of these factors in the development and maintenance of a productive therapeutic alliance. 11,17 As an individual, the physician absorbs the general principles and particular features of the culture of medicine as practised in his or her location and filtered through his or her own cultural background. The patient's cultural background brings with it conceptions of trust, respect for authority figures, dignity, self-image, self-esteem, and family-nourished beliefs and attitudes, that the physician needs to appreciate to develop a positive and productive therapeutic alliance. In psychiatry, the therapeutic alliance is also affected by prejudice, stigma, including selfstigmatization, 18 and discrimination-powerful cultural forces in most societies. Culture and psychiatric treatment Cultural competence is important not only in diagnosis and the therapeutic alliance but also in the formulation and execution of a treatment plan. 11 The patient's culture might influence his or her willingness to engage in the type of emotional self-disclosure that is essential for all forms of psychotherapy. Cultural and spiritual beliefs might influence the patient's perception that there is an internal locus of control of their thoughts, emotions, and behaviours. Both these factors would influence, for example, a prescription for psychotherapy and its implementation. Thus, the development and use of culturally sensitive psychotherapies and psychosocial interventions should be encouraged. In some cultures, pharmacotherapy prescription might be affected by traditional medicinal treatments and potential conflicts with traditional healers which must receive particular attention from the psychiatrist. 19 The cultural aspects of all components of the psychiatric care system should receive much more emphasis in the coming decade, with resources devoted to training, research, and clinical system development aimed to better equip clinicians to provide excellent culturally competent care. 20,21 Culture and Stigma Culturally influenced discrimination against those with psychiatric illnesses, their families, and those who provide treatment for them has been known for centuries in essentially every society or...