Cross-cultural & Global mental health
LECTURES (2022)
LEC 1 Introduction: concepts and epidemiology……………………………………………………………….p. 2
▪ History global mental health
▪ WHO’s 5 phase model of new intervention testing
▪ Psychological interventions
LEC 2 Cultural adaptations of interventions for use in global settings…………………………………….p. 5
▪ Cultural adaptation of interventions
▪ Bernal’s framework
LEC 3 Culture and diagnosis………………………………………………………………………………….…….p. 8
▪ Disorders
LEC 4 Mental health and psychosocial support for adults and children in post disaster settings…...p.10
▪ Background global mental health
▪ Supporting children affected by armed conflict
▪ Integration of mental health into primary health care in post-conflict and earthquake affected Nepal
LEC 5 Integrating culture and context into trauma-focused treatment in culturally diverse
populations…………………………………………………………………………………………………………….p.12
▪ Refugees experiences
▪ Posttraumatic stress dissorder due to sogie-based violence and persecution in sexual and gender minority
refugees
▪ Minority stress
LEC 6 Integrating culture and context into trauma-focused treatment in culturally diverse
populations……………………………………………………………………………………………….………..….p.17
▪ Mental health problems among refugees and migrants
▪ Scalable psychological interventions to address mental health problems
LEC 7 Social exclusion and severe mental illness ………………………………….…………………………p.18
CASES……………………………………………………………………………………………….……………...….p.20
1
, LEC 1 Introduction: concepts and epidemiology
Topics
▪ History global mental health
▪ WHO’s 5 phase model of new intervention testing
▪ Psychological interventions
Definition global health An evolving field of research and practice that aims to alleviate mental suffering
through the prevention, care and treatment of mental and substance use disorders,
and to promote and sustain the mental health of individuals and communities around
the world.
Historical context 8th century: Institutional psychiatric care developed in Islamic world
▪ Included both physical and psychosocial treatments
▪ People were given semantic treatment like cupping, but they were also socially
treated. However, they were also chained when disturbing symptoms occurred to
prevent harming others.
12th -15th century: Psychiatric institutions established in Europe
▪ During colonialism, spread of mental asylums across Africa and Asia
▪ Across many low- and middle income countries, mental asylums still dominant
form of mental healthcare
1950-1960s: Shift from institutional Care to Community-Based Mental Health Care
(CBMH)
▪ Increased belief in efficacy of CBMH
▪ Disadvantages of institutionalization (abusive conditions, negative effects)
▪ Costs of institutionalization
▪ Discovery of antipsychotics (e.g., chlorpromazine, 1954)
▪ Appreciation of human rights of individuals with mental disorders
Emic vs. etic Emic approach (social anthropologists and cultural psychiatrists):
approaches Human experience is shaped by culture and there is no such thing as universal
psychiatric syndromes
Etic approach (clinicians and epidemiologists):
Core symptoms of psychopathology are product of universal biological or
psychological processes
Global mental health ▪ From 1970s: integration of emic and etic approaches to interdisciplinary
research cross-cultural psychiatry approach
▪ From 2000s: Epidemiological studies across diverse populations and in LMICs
▪ After 2005: Large Randomized Controlled Trials (RCTs) appeared
Mixed methods research Mixed methods research includes qualitative and quantitative approaches.
Qualitative:
• More often used for exploratory research
• Fieldwork, ethnography
• Data gathered through observation or in-depth interviews
• Recruitment via snow-ball or purposive sampling
• Inclusion of new participants until “saturation”
• No uniform procedures, procedures may vary from person to person
• Audio-recording and making transcripts
• Identifying themes and marking categories of themes
Quantitative:
• More often used for confirmatory research
2
, • Hypotheses are focused
• Numerical data are gathered
• Larger sample sizes in order to generalize results across populations
• Uniform procedures
WHO’s 5 phase model
for new intervention
testing
1. Adaptation of interventions for local sociocultural context
2. Pilot RCT
- When there is an effect but it’s smaller effect it might not be a
powerful intervention. You do need a larger RCT because the
power-analysis is based on effect size. You can also conclude that
because it’s a cost full intervention you only want a large effect.
3. Process evaluation to prepare for RCT
4. Larger RCT to evaluate
5. Process evaluation for implementation
Mental health treatment ▪ Discrepancy between people in need of mental health care, and people receiving
Gap mental health care
▪ Range: 1.6% in Nigeria to 17.9% in USA
▪ Reasons:
- Stigma
- Poor access
- Limited financial resources for mental health care
▪ Solution → Integrating mental health care into community
Community Providers within health care: community health workers, school nurses
or counselors, workplace health providers
Community Providers outside health care:
Village elders, traditional healers, faith group leaders, other community leaders or
members of the community (peers), families and friends of people with mental health
conditions
Task shifting Tasks originally performed by health care professionals are transferred to
non-specialist community workers or lay persons.
- Reduced disability and improved overall and social functioning
Intervention pyramid ▪ If people are in need and you need to come there to think of interventions, you can
(IASC, 2010) think of interventions that are somewhere in this pyramid.
▪ Strengthening: the whole community needs support; activating social networks for
example.
▪ Basic emotional and practical support: focused person to person support.
3
LECTURES (2022)
LEC 1 Introduction: concepts and epidemiology……………………………………………………………….p. 2
▪ History global mental health
▪ WHO’s 5 phase model of new intervention testing
▪ Psychological interventions
LEC 2 Cultural adaptations of interventions for use in global settings…………………………………….p. 5
▪ Cultural adaptation of interventions
▪ Bernal’s framework
LEC 3 Culture and diagnosis………………………………………………………………………………….…….p. 8
▪ Disorders
LEC 4 Mental health and psychosocial support for adults and children in post disaster settings…...p.10
▪ Background global mental health
▪ Supporting children affected by armed conflict
▪ Integration of mental health into primary health care in post-conflict and earthquake affected Nepal
LEC 5 Integrating culture and context into trauma-focused treatment in culturally diverse
populations…………………………………………………………………………………………………………….p.12
▪ Refugees experiences
▪ Posttraumatic stress dissorder due to sogie-based violence and persecution in sexual and gender minority
refugees
▪ Minority stress
LEC 6 Integrating culture and context into trauma-focused treatment in culturally diverse
populations……………………………………………………………………………………………….………..….p.17
▪ Mental health problems among refugees and migrants
▪ Scalable psychological interventions to address mental health problems
LEC 7 Social exclusion and severe mental illness ………………………………….…………………………p.18
CASES……………………………………………………………………………………………….……………...….p.20
1
, LEC 1 Introduction: concepts and epidemiology
Topics
▪ History global mental health
▪ WHO’s 5 phase model of new intervention testing
▪ Psychological interventions
Definition global health An evolving field of research and practice that aims to alleviate mental suffering
through the prevention, care and treatment of mental and substance use disorders,
and to promote and sustain the mental health of individuals and communities around
the world.
Historical context 8th century: Institutional psychiatric care developed in Islamic world
▪ Included both physical and psychosocial treatments
▪ People were given semantic treatment like cupping, but they were also socially
treated. However, they were also chained when disturbing symptoms occurred to
prevent harming others.
12th -15th century: Psychiatric institutions established in Europe
▪ During colonialism, spread of mental asylums across Africa and Asia
▪ Across many low- and middle income countries, mental asylums still dominant
form of mental healthcare
1950-1960s: Shift from institutional Care to Community-Based Mental Health Care
(CBMH)
▪ Increased belief in efficacy of CBMH
▪ Disadvantages of institutionalization (abusive conditions, negative effects)
▪ Costs of institutionalization
▪ Discovery of antipsychotics (e.g., chlorpromazine, 1954)
▪ Appreciation of human rights of individuals with mental disorders
Emic vs. etic Emic approach (social anthropologists and cultural psychiatrists):
approaches Human experience is shaped by culture and there is no such thing as universal
psychiatric syndromes
Etic approach (clinicians and epidemiologists):
Core symptoms of psychopathology are product of universal biological or
psychological processes
Global mental health ▪ From 1970s: integration of emic and etic approaches to interdisciplinary
research cross-cultural psychiatry approach
▪ From 2000s: Epidemiological studies across diverse populations and in LMICs
▪ After 2005: Large Randomized Controlled Trials (RCTs) appeared
Mixed methods research Mixed methods research includes qualitative and quantitative approaches.
Qualitative:
• More often used for exploratory research
• Fieldwork, ethnography
• Data gathered through observation or in-depth interviews
• Recruitment via snow-ball or purposive sampling
• Inclusion of new participants until “saturation”
• No uniform procedures, procedures may vary from person to person
• Audio-recording and making transcripts
• Identifying themes and marking categories of themes
Quantitative:
• More often used for confirmatory research
2
, • Hypotheses are focused
• Numerical data are gathered
• Larger sample sizes in order to generalize results across populations
• Uniform procedures
WHO’s 5 phase model
for new intervention
testing
1. Adaptation of interventions for local sociocultural context
2. Pilot RCT
- When there is an effect but it’s smaller effect it might not be a
powerful intervention. You do need a larger RCT because the
power-analysis is based on effect size. You can also conclude that
because it’s a cost full intervention you only want a large effect.
3. Process evaluation to prepare for RCT
4. Larger RCT to evaluate
5. Process evaluation for implementation
Mental health treatment ▪ Discrepancy between people in need of mental health care, and people receiving
Gap mental health care
▪ Range: 1.6% in Nigeria to 17.9% in USA
▪ Reasons:
- Stigma
- Poor access
- Limited financial resources for mental health care
▪ Solution → Integrating mental health care into community
Community Providers within health care: community health workers, school nurses
or counselors, workplace health providers
Community Providers outside health care:
Village elders, traditional healers, faith group leaders, other community leaders or
members of the community (peers), families and friends of people with mental health
conditions
Task shifting Tasks originally performed by health care professionals are transferred to
non-specialist community workers or lay persons.
- Reduced disability and improved overall and social functioning
Intervention pyramid ▪ If people are in need and you need to come there to think of interventions, you can
(IASC, 2010) think of interventions that are somewhere in this pyramid.
▪ Strengthening: the whole community needs support; activating social networks for
example.
▪ Basic emotional and practical support: focused person to person support.
3
