Movement for Global Mental Health: The crusade and its critique.

The Movement for Global Mental Health (MGMH)1 aims to improve services for people with mental health problems worldwide, with a focus on low- and middle-income countries (LMIC). The core principles of this movement include scientific evidence and human rights. It is a broad coalition led by psychiatry and its membership now includes over 200 institutions and 10 000 individuals. The movement is a product of the call for action of the Lancet Global Mental Health Series.2 The components of the movement include advocacy, human rights, universal healthcare, policy, research and programmes relevant to LMIC.1 Its main aim is to focus on the post 2015 Millennium Development Goals (MDGs) including mental health. The movement has inspired many field studies and has developed resources.1 Support for the movement also comes from the WHO and its recent plans and programmes, which include Mental Health Gap Action Programme (mhGAP),3 Mental Health Evidence and Research (MER) and the Comprehensive Mental Health Action Plan 2013–2020. The mhGAP3 recognizes the burden of mental illness, identifies limitations in service delivery, highlights gaps in treatment and services and attempts to bridge the void. Its resources include an intervention guide for common disorders, resources, projects and publications. The core projects of the WHOs Mental Health Evidence and Research programme are the Mental Health Atlas 2011,4 which maps mental health resources across countries,4 the Assessment Instruments for Mental Health Systems (AIMS), which allows for uniformity of assessment of services,5 and Mental Health in Emergencies.6 The major objectives of the WHO’s Comprehensive Mental Health Action Plan 2013–207 include strengthening effective leadership and governance for mental health, providing comprehensive, integrated and responsive mental health and social care services in community-based settings, implementing strategies for promotion and prevention in mental health and strengthening information system, evidence and research in mental health. Its cross-cutting principles include universal health coverage, human rights, evidence-based practice, life-course and multisectoral approaches and the empowerment of people with mental disorders and psychosocial disabilities. The plan aims to restructure, reinvigorate and invest in mental health services.7 It provides a framework for national governments, development agencies, academia and civil society. It provides broad and objective measurable indicators and targets for key priorities including service coverage, updating mental health policies and laws, reducing rates of suicide, improving data collection to evaluate implementation, progress and impact. The case to scale up services has the following rationale: (i) to

Robert Spitzer and psychiatric classification: technical challenges and ethical dilemmas.

Dr Robert Leopold Spitzer (May 22, 1932–December 25, 2015), the architect of modern psychiatric diagnostic criteria and classification, died recently at the age of 83 in Seattle. Under his leadership, the American Psychiatric Association’s (APA) Diagnostic and Statistical Manuals (DSM) became the international standard.

Nutritional status and intellectual development in children: A community-based study from rural Southern India.

Background. There is a dearth of recent data on the relationship between nutritional status and intellectual development among children in India. To determine whether such a relationship exists, we studied children in a rural area of Tamil Nadu. Methods. We stratified villages in Kaniyambadi block, Tamil Nadu, and recruited consecutive children who satisfied the study criteria. We assessed nutritional status by measuring height and weight and recording chronological age, and calculated indices weight-for-age, height-for-age, weight-forheight and their Z scores. We assessed intellectual development using the Indian adaptation of the Vineland Social Maturity Scale. We used a case–control framework to determine the relationship and logistic regression to adjust for common confounders. Results. We recruited 114 children between the ages of 12 and 72 months. Z score means (weight-for-age –1.36; height-for-age –1.42; weight-for-height –0.78) were much less than 0 and indicate undernutrition. Z score standard deviations (weight-for-age 1.04; height-for-age 1.18; weightfor-height 1.06) were within the WHO recommended range for good quality of nutrition data suggesting reduced measurement errors and incorrect reporting of age. The frequency distributions of population Z scores suggest high undernutrition, wasting and medium stunting. A tenth of the population (9.6%) had values to suggest borderline/below average intelligence (social quotient <89). Lower height-forage, height-for-age Z score and weight-for-height Z score were significantly associated with a lower social quotient. These relationships remained statistically significant after adjusting for sex and socioeconomic status using logistic regression. Conclusion. Chronic undernutrition, wasting and stunting and their association with lower intellectual development demand an urgent re-assessment of national food policies and programmes. Natl Med J India 2016;29:82–4

Gay rights and bigotry.

Every day heterosexist ideals and norms encourage homophobia and prejudice. We need to be aware of and debate sophisticated forms of bigotry in today’s world. Modern medicine and psychiatry, since the 1970s, have abandoned pathologizing same-sex orientation and behaviour.1 The WHO accepts same-sex orientation as a normal variant of human sexuality.2 The United Nations Human Rights Council values Lesbian Gay Bisexual and Transgender (LGBT) rights.3 Yet, India’s Supreme Court reinstated a law that bans gay sex by restoring Section 377 of the Indian Penal Code.4 The response from the mental health and legal establishment to this manifest bigotry was weak.5–7 It betrayed a poor understanding of the issues and reflected deeply ingrained prejudices.

Post-traumatic stress disorder: Psychiatric management, atonement and justice.

Post-traumatic stress disorder (PTSD), initially described in Vietnam war veterans, is now a standard psychiatric diagnosis and used across cultures, contexts and around the globe. It is incorporated in the American Psychiatric Association’s Diagnostic and Statistical Manual-5 (DSM-5)1 and is to be a part of the WHO’s International Classification of Diseases-11.2 Despite its widespread acceptance as a disease label, there are many unresolved issues related to the category.3–10 Many of the problems of facing psychiatric diagnoses and classification also plague PTSD. Unpleasant feelings (e.g. anxiety, dreams and memory) within the normal range of emotions and purposive responses of people who are stressed (e.g. efforts to avoid thoughts, feelings, conversations, activities, places associated with the traumatic event) are considered pathological.4–6,7 The reasonable reactions to specific contexts (e.g. hyper-vigilance or numbing) are labelled aberrant. The lack of pathognomonic symptoms, marked overlap of symptoms with other categories (e.g. major depression, specific phobia, generalized anxiety disorder, dissociative disorder, etc.) and absence of diagnostic laboratory tests add to the confusion.3,4,6,7 Psychiatry employs symptom checklists for diagnosis and the process discounts the context; the diagnostic procedure does not examine the pre- and post-trauma setting, vulnerability and supports. The ‘atheoretical’ approach adopted by the current psychiatric classifications essentially supports the medical model, which medicalizes personal and social distress.3,4,6,7 The PTSD category is now also used in people who are victims of violence in the civilian settings and who have survived rape, assault, accidents, communal pogroms, industrial disasters, tsunamis, etc. The diagnosis also assumes that the trauma has past and that the current context is safe. While this may be true for war veterans who have come home, it may not be true for other civilian victims of assault, for women in patriarchal cultures, ethnic, religious and sexual minorities in traditional societies, where continued threats and violence are possible.6,7 The concept discounts variation among different people and does not highlight the strength of the survivors or the meaning of the event.6,7,10 Problems in living, when viewed through the medical lens, are construed as mental disorders.3–7 The legal, insurance and compensation implications of the label are complex and influence the category and criteria. However, research evidence for the usefulness of psychiatric treatment after natural and manmade disasters is thin.11 Similarly, the success of prevention and treatment programmes for veterans is limited.8 Nevertheless, recent articles about experience in wars have discussed different conceptualizations, opposed to the medical

The challenge of medical diagnosis: A primer on principles, probability, process and pitfalls.

Arriving at a medical diagnosis is a complex process, which requires clinical skill. However, the need for clear decisions has to be balanced by an acceptance of the ambiguity of many clinical situations. Complex presentations often require probabilistic inferences rather than presumed diagnostic certainty. The demands, logic and process of clinical diagnosis are highlighted. The multiple aspects of clinical reality and the impact of gold standards, nature of evidence and dichotomous disease/no disease categorization are discussed. The importance of population characteristics and context in diagnosis and prediction are emphasized. The statistics of agreement, Bayesian approach, certainty and risk, hazards and pitfalls, common errors, audit and the influence of commercialization on diagnosis are addressed. There is a need to formally teach the art and science of medicine and to transfer clinical skill rather than hope that such skills will be automatically imbibed during training.

Critical perspectives on the NIMH initiative “Grand Challenges to Global Mental Health”.

In July 2011 Nature carried a Comment titled “Grand Challenges to Global Mental Health”announcing research priorities to benefit people with mental illness around the world. The essay called for urgent action and investment. However, many professionals, academics, and service user advocate organisations were concerned about the assumptions embedded in the approaches advocated and the potential for the project to do more harm than good as a result. Nature refused to print a letter (sent on 20th August 2011) protesting against the issue, citing ‘lack of space’ as the reason. This letter is an effort to critique the initiative through wide participation and consensus