Global Mental Health Flashcards
Biopsychosocial model of intervention for mental disorders?
[Venn Diagram]
An overlap of the following…
Psychological (e.g. CBT)
Biological (meds: ADs or antipsychotics, ECT)
Social/Environmental (social support, practical, financial/employment, tacking triggers e.g. abuse/bullying)
NB: optimum intervention usually needs parallel and coordinated multimodal interventions
Examples of evidence-based psychological interventions for mental disorders (name at least 4)?
BTW: KNOW A BIT ABOUT THE EXAMPLES I LIST
NB: these were all developed in high income countries
- CBT
- Cognitive Analytical Therapy (CAT)]- look at past patterns
- interpersonal psychotherapy]- resolving interpersonal problems
- family therapy]- solving problems within family
- motivational interviewing]- resolve ambivalent feelings & insecurities to change behaviour
(- EMDR
- Brief Solution focused therapy
- psychodynamic psychotherapy
- EMDR
- Dialectical Behaviour Therapy (DBT))
Simplified rational for CBT?
[Cycle]
Behaviour -> Throughts -> Feelings -> Behaviour (etc…)
People experience the same events differently: mainly how we THINK about the experience (not the experience itself)
Changing one area (thoughts/behaviour/feelings) can change others; like a domino effect
Components of CBT?
CBT is actually 2 therapies
Cogntive therapy AND Behavioural therapy
CBT efficacy in LMICs?
Efficacious, but appropriate adaptations are required
-> Group Interpersonal Therapy (simplified format for those who lack training)
Why does CBT structure need adaptation for LMICs [minor problems]?
- professionals required (psychiatrists)
- sessions too long
- too many sessions
- not enough people trained in delivering CBT
Why does CBT nature need adapting for LMICs [major problems]?
- less resources available for mental health (financial and human resources)
- how costs are covered (NGOs, government, employers, private insurance)
- language differences (associated lexicons too) because CBT was developed in HICs
- cultural differences
- distance/logistics (pts travel long distances at huge expense)
- service organisation
Cultural difrerences between LMICs and HICs
LMIC
- family/group oriented
- hierarchical pt-therapist relationship]- otherwise seen as lack of expertise
- religious coping is common
HIC
- individual oriented
- collaborative pt-therapist relationship
- religious coping is less common
Outline the issues of service organisation in LMICs compared to HICs
Referral pathways for CBT may not exist/not be understandable or accessible to the clinician or patient
The clinician seeing the pt may be the only person who can offer CBT techniques (as pt may not be seen again)
List examples of adaptations made to CBT in LMICs
- group intervention
- delivery by lay/non-specialist workers
- content: more behavioural and less cognitive
- more directive appoach (consistent w/ hierarchical pt-therapist relationship of LMICs)
- language (adapt, translate into local language w/ idioms + metaphors)
- incorporate existing helpful cultural/religious coping strategies
- involve families
- using internet and mobile phones
Describe group intervention
- More cost-effective
- Fits collectivist nature of LMICs
- (E): Meta-anaylses of CBT in depression and anxiety consistently find group therapy to be as effective as individual therapy
Describe the use of lay/non-specialist workers
CBT principles are easy to convey to non-specialists and non-healthcare professionals e.g. teachers
CBT lends itself readily to manualisation
Several RCTs of CBT in LMICs show good outcomes of non-specialist delivered treatments using manuals developed + supervised by specialists
Benefits of making CBT more behavioural and less cognitive in LMICs
Behavioural techniques are:
- easier to explain (esp by less skilled clinicians)
- quicker to understand and relatively easier to use
- as effective as cognitive interventions/full CBT
Negative effects of religion on mental health?
- guilt
- promotes anhedonia
- promotes stigma
- harmful practices (e.g. chaining and beating)
- reduced treatment adherance (e.g. fasting)
Postive effects of religion on mental health?
- finding meaning of one’s life
- more positive appraisal of negative events
- external attribution of negative events (e.g. blame the devil)
promotion of positive effect (e.g. count your blessings) - social support
- positive social guidance (teaching of moderation)
- opportunity to give or serve
- promoting/sustaining hope in hopeless circumstances (can reduce suicidality)
Benefits of involving families for CBT in LMICs
Can remind pts of CBT techniques (as it’s possible that you may never see pt again)
Benefits of using internet and mobile phones for CBT in LMICs?
Number of internet users has greatly increased (5.7-39% from 2004-2016)
Opportunities for:
- online/mobile phone delivery platforms for psychological therapy
- remote supervision of therapists
When CBT might not be helpful in LMICs?
If pt’s negative cognitions are:
- genuine loss following bereavement
- genuine fear (bullying/persecution)
NB: but some behavioural interventions may be helpful in such situations (e.g. relaxation techniques)
Alternatives if CBT is not helpful?
- medications (e.g. SSRIs for anxiety/depression/OCD/PTSD)
- supportive therapy (bereavement counselling following a loss)
- practical problem solving & advocacy (if negative cognitions are driven by genuine problems like bullying)
- family therapy (if negative family dynamics is cause)
- dialectical behavioural therapy incorporating radical acceptance, distress tolerance and mindfulness
What is radical acceptance?
Accepting a painful reality you can’t help AND accepting that life can still be worth living despite the pain
Not accepting a pain that is unavoidable prolongs suffering and agony, interfering w/ pt’s capacity to move on from the past and take up new opportunities presenting themselves now and in future
Challenges Western beliefs that pain shouldn’t be tolerated and perpetual comfort (hedonism) is achievable.
-> find ways to cope with pain e.g. distress tolerance techniques and mindfulness
Examples of distress tolerance techniques?
- positive distraction (e.g. music, funny youtube clips, puzzles)
- relaxation techniques (slow breathing, muscle relaxation, yoga)
- positive self talk
- helping others (volunteering)
- prayer
- mindfulness
Describe mindfulness
[can be it’s own therapy or part of DBT or CBT]
Involves paying attention to the present rather than the past/future
Bringing back mind from wandering off (into negative thoughts)
