From: "Saved by Windows Internet Explorer 8" Subject: How scientifically valid is the knowledge base of global mental health? -- Summerfield 336 (7651): 992 -- BMJ Date: Thu, 31 Dec 2009 11:11:06 -0000 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CA8A09.F27F7AE0" X-MimeOLE: Produced By Microsoft MimeOLE V6.0.6002.18005 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CA8A09.F27F7AE0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.bmj.com/cgi/content/full/336/7651/992
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BMJ 2008;336:992-994 (3 May),=20 doi:10.1136/bmj.39513.441030.AD
Derek Summerfield, honorary senior=20 lecturer
1 Institute of Psychiatry, King=92s College, London SE5 = 8AF
derek.summerfield{at}slam.nhs.uk
Mental health is a construct that cannot be seen = as=20 independent of culture, society and situation. Derek = Summerfield=20 argues that Western definitions and solutions cannot be = routinely=20 applied to people in developing countries
Global mental health now has its own academic units, literature, = study, and training courses and the World Health Organization = is a major articulator of this work. Last September, a series = on global mental health in the Lancet asserted that mental=20 disorders now represent a substantial "though largely hidden" = proportion of the world=92s overall disease burden, that = every=20 year up to 30% of the global population would develop some = form=20 of disorder, and that there was strong evidence for scaling = up=20 mental health services worldwide.1 2 In this=20 article I examine the evidence for these claims and challenge = the=20 assumption that Western frameworks can generate a universally = valid=20 knowledge base.
Psychiatric research and practice rest on empiricist convention=20 rather than on timeless discovery. The principal = classification=20 systems, the International Classification of Diseases = (ICD)=20 and the Diagnostic and Statistical Manual of Mental = Disorders=20 (DSM), are shaped by contemporary notions about what = constitutes=20 a real disorder, what counts as scientific evidence, and how=20 research should be conducted. They are Western cultural = documents=20 par excellence.3=20
The diagnostic categories within these classifications are = essentially=20 conceptual devices emerging from committee decisions. The = authors=20 of both of these classifications are careful to point out = that=20 "there is no assumption that each category of mental disorder = is a completely discrete entity with absolute boundaries = dividing=20 it from other mental disorders or from no disorder."4=20 Despite this, in everyday practice these categories have been = effectively accepted as if they were unequivocal diseases = like, say,=20 tuberculosis.
Claims for the universality of a particular psychiatric category = would be compelling if a straightforward biological cause had = been established. But this is the case for only a few = categories=20 in the Western psychiatric canon. Official psychiatric = categories=20 evolve, disappear, or appear, reflecting Western social and=20 cultural trends as much as medical thinking. For example, = DSM-III,=20 published in 1980, expunged homosexuality as a classified = mental=20 illness and installed post-traumatic stress disorder for the=20 first time. It would be extraordinary if these classification = systems made sense across the great diversity of societies = and=20 situations worldwide.
The psychiatric literature contains large numbers of studies = of=20 non-Western subjects, and publications on refugees and populations=20 affected by disaster rose exponentially during the 1990s.5=20 However, in a review of 183 published studies on the mental = health=20 of refugees, four fifths of the studies relied exclusively on = measures of psychopathology developed with Western=20 populations.6=20 Although a few researchers have sought to garner culture = specific=20 information, they too have retained Western psychiatric = categories as=20 their basic template.7 8=20
The relevance of much of this published literature is therefore=20 questionable because it fails the fundamental test of = scientific=20 validity. Validity is a concept meant to assess "the nature = of=20 reality" for the people being studied. Methods for research = into the=20 mind cannot rely on the merely technical and quantifiable, = since "the=20 nature of reality" is bound up with local forms of knowledge = and=20 philosophy. To ignore the test that follows =96 whose = reality, whose=20 knowledge, whose philosophy =96 is to risk pseudodiagnoses = and=20 interventions that are an unwanted distraction in the hard = pressed=20 lives of non-Western subjects.
It is telling that published studies of non-Western populations=20
often refer to participants=92 "limited knowledge of mental=20
disorders," their lack of "mental health literacy," or the =
need=20
to "teach" health workers and the people they serve about =
mental=20
health. Here Western psychological discourse is setting out =
to=20
instruct, regulate, and modernise, presenting as definitive =
the=20
contemporary Western way of being a person. It is unclear why =
this=20
should be good for mental health in Africa or Asia. This is =
medical=20
imperialism, similar to the marginalisation of indigenous =
knowledge=20
systems in the colonial era, and is generally to the =
disadvantage of=20
local populations.9 10=20
Many ethnomedical systems have categories that range across =
the=20
physical, supernatural, and moral realms and do not conceive =
of=20
illness as situated in body or mind alone.11=20
Distress is commonly understood and expressed in terms of =
disruptions=20
to the social and moral order. As Kleinman and Good put it,=20
"Cultural worlds may differ so dramatically that translation =
of=20
emotional terms means more than finding semantic equivalents. =
Describing how it feels to be aggrieved or melancholic in =
another=20
society leads directly into an analysis of a radically =
different=20
way of being a person."12=20
Since the 1970s many ethnographic studies have shown that the=20
presentation, attribution, classification, prevalence, and =
prognosis=20
of mental disorders varies greatly between cultures. Journals =
such as Social Science and Medicine, Transcultural =
Psychiatry,=20
Anthropology and Medicine, and Culture, Medicine and=20
Psychiatry are replete with this work. However, it is=20
under-represented in the mainstream psychiatric literature, =
which=20
tends to overemphasise cross-cultural similarities and =
minimise the=20
differences.13=20
WHO has stated that "depression" is a worldwide epidemic that=20
within a decade will be second only to cardiovascular disease =
in terms of global disease burden. But it is a basic error of =
validity to assume that because Western mental phenomena can =
be=20
identified in non-Western settings, they mean the same as =
they do in=20
the Western world. Some central and southern African =
societies=20
recognise a local condition - often translated as "thinking =
too much"=20
=96 which has some physiological overlap with Western =
depression, but=20
the understandings, attributions, and remedies applied to it =
are very=20
different.
As discussed above, the DSM or ICD definition of depression =
is=20
merely a descriptive syndrome, highly heterogeneous and socially=20
shaped, albeit subsuming a small subset of severely =
dysfunctional=20
people who do fit the model of depression as a disease. This=20
term simply cannot be used (as WHO uses it) to denote a =
universally=20
valid mental disorder that is amenable to a standard mental=20
health toolkit.14=20
A meta-analysis of 56 published studies of refugees=92 mental =
health=20
totalling 67 294 participants found the strongest moderating =
factor=20
to be social conditions after displacement.15=20
Resolution of the conflict that had displaced them also had =
positive=20
effects. This suggests that the mental phenomena being =
identified=20
as satisfying criteria for a mental disorder (typically=20
depression or post-traumatic stress disorder) were mostly =
incidental=20
and a normal reaction to their circumstances.15 My=20
research and clinical experience in war affected rural =
Zimbabwe, with=20
rural peasants and wounded former soldiers in Nicaragua, and=20
with HIV positive African women and other asylum seekers in =
the=20
United Kingdom indicated that a diagnosis such as depression, =
although commonly made, had little power to explain their=20
problems.16=20
17=20
Lastly, WHO is backing the global application of technologies =
like=20
checklists to estimate population prevalences of depression =
and the=20
therapeutic value of antidepressants or counselling when the =
strength=20
of their evidence base even in Western societies remains=20
controversial.18=20
Social scientists agree that wellbeing and personal resilience =
are=20
linked to social connectedness and the sense of a coherent =
world.=20
Throughout the non-Western world, structural poverty and =
injustice,=20
violent conflict, debt repayments, shifting weather patterns, =
environmental degradation, and inadequate budgets for health, =
education, and social welfare provide a barely viable social =
context=20
for millions of people. Around 85% of Kenya=92s population =
growth in=20
the 1990s was absorbed into the slums of Nairobi and Mombasa, =
reflecting a rapid withering of traditionally self sufficient =
ways of=20
life.19=20
Average life expectancy is falling in many countries, and one =
third=20
of the world=92s children are undernourished. Can psychiatric =
approaches honed in relatively well resourced and stable =
societies=20
distinguish mental disorder from normal responses to a social =
world=20
that is no longer coherent or functional? The danger of the=20
medicalisation of everyday life is that it deflects attention =
from=20
what millions of people worldwide might cite as the basis of =
their=20
distress - for example, poverty and lack of rights. =
Until these fundamental queries about the knowledge base are=20
answered, claims about the current state of global mental =
health=20
seem risible. There needs to be agreement that Western =
psychiatry=20
is but one among many ethnopsychiatries. New research ideally =
needs to engage with participants in a way that carries no =
preformed=20
notions about what is "mental" or "health" in their world: =
local=20
concepts must be the starting point for the creation of valid =
instruments for screening or diagnosis.
The so called common mental disorders, such as post-traumatic=20
stress disorder and depression, have strongly featured in the =
research literature to date, but there are reasons to query =
how=20
much the impetus for this has come from those on the ground, =
as=20
opposed to interested parties from outside. WHO=92s prevalence =
figures=20
lack credibility and would seriously mislead health planners =
and=20
providers.
Research into more severe mental disorders is on firmer ground.=20
These disorders are much more likely to have a =
neuropsychiatric=20
component and to stretch local social and healthcare =
resources.=20
Based on a survey of 2739 households, Patel and colleagues =
estimated=20
standardised prevalence ratios of psychosis (2.79), learning=20
difficulties (1.48), and seizures (2.00) (seizures are =
commonly=20
seen as a mental disorder in much of Africa) in rural and =
urban=20
Mozambique.20=20
Psychosis would not of course be a homogeneous category, =
since it=20
would subsume various organic cerebral states that merited =
attention=20
in their own right =96 not least AIDS encephalopathy or =
dementia.=20
An emphasis on qualitative work would promote more grass roots=20
ownership of the terms of reference of mental health and =
enable=20
a robust and relevant knowledge base to emerge. The apparent=20
failure of the =A31.1 trillion spent on development aid =
in Africa=20
over the past 50 years to change anything is partly because =
donors=20
lacked knowledge of the situations on the ground in poor =
countries=20
and because of over-reliance on expensive consultants from =
donor=20
countries.21 Local=20
voices were weakly represented. This poses an ethical =
challenge for=20
global mental health: non-Western people can give properly =
informed=20
consent only if the terms in which they are being =
represented,=20
which here means candidature for psychiatric caseness, are =
not=20
alien or irrelevant to their interpretations of the =
world.=20
Competing interests: None =
declared.
Provenance and peer review: Not =
commissioned;=20
externally peer reviewed.
Read all Rapid=20
ResponsesCultural variability of mental disorder
Depression as an example
Mental health in a broken social world
Valid assessment
Summary=20
points
=
Contributors and sources: DS has studied, =
lectured,=20
and published widely on health and human rights in Africa, =
Central=20
America, and the Middle East, particularly in war affected=20
populations and on asylum seekers in the UK. He is also a =
teaching=20
associate at Refugee Studies Centre, University of =
Oxford.=20
References
(Accepted 26 January 2008)
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