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Euro-American idioms of distress and their corresponding symptom clusters have been universalised as mental disorders and are now the gold standard for psychiatric diagnosis around the globe. This paper discusses issues related to mental disorder diagnosis from a cultural perspective. It argues that psychiatric diagnoses, while having good inter-rater reliability, lack external validity. It contends that psychiatric categories and labels are supported by the current political economy of health. Nevertheless, it suggests that (i) all symptoms have a metaphoricity to convey a variety of distress, (ii) idioms are polysemious and have a capacity for multiple meaning and pragmatic implications, beyond local and cultural inferences, (iii) idioms of distress are performative, are a form of social action that effects social change, and are prone to improvisation of expression that is associated with adoption in new and changing contexts, (iv) psychiatric idioms are as easily accepted as local and folk beliefs and expressions, (v) idioms of distress are used for negotiating access to care, cure and healing across regions and cultures. The paper argues that new (psychiatric) idioms are easily adopted across regions and societies, and that they eventually change contexts and cultures., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The majority of persons with mental distress (PWMD) in India do not have access to care, and even those who seek care are pushed to attend private providers, given the weak and largely absent public mental health services framework. The aim of this study was to examine the experiences in help-seeking and with unethical health service provision among persons with mental distress in the Saharanpur and Bijnor districts of Uttar Pradesh. In-depth interviews were conducted with twenty persons with mental distress and their caregivers. Thematic analysis yielded four key findings about help-seeking: first, that it was syncretic and persistent; second, that expenditure for private care was high and often catastrophic; third, that investigations and care provided were pharmacological and predominantly irrational and excessive; and lastly, that help-seeking was abandoned. This study demonstrates that PWMD are particularly vulnerable to exploitation by private providers with illnesses that are stigmatising, poorly understood, chronic, relapsing, and disabling and that often require complex management. Responding to mental distress requires multiple empowering and interacting policy and programme initiatives that must include regulation of private and public providers, resources, and actions to strengthen public and primary mental healthcare and promotion of mental health competence in communities.

Purpose of Review: Patient and physician perspectives about mental health, illness, and recovery, which affect different aspects of help seeking and healthcare, needs to be understood and theorized., Recent Findings: People seem to simultaneously hold multiple and contradictory illness beliefs and seek help from diverse sources of cure and healing. Explanatory models elicited at baseline do not predict outcomes of illness, change over time, and are dependent on the interaction between the trajectory of individual's illness and the sociocultural milieu. Illness narratives contextualize the patient, describe the patient's reality and his/her ways of coping, and attempt to make sense of illness experiences, control them, and improve quality of life. On the other hand, diversity of beliefs among psychiatrists, family physicians, and public health specialists is dependent on their disciplinary perspectives. Nevertheless, the variability within psychiatric syndromes and the inability to predict individual trajectories of illness support cultural beliefs about uncertainties of life. These are identified by cultures through idioms and metaphors and labeled as luck, chance, karma, fate, punishment by God, evil spirits, black magic, disease and so on., Summary: There is a need for a broad-based approach to mental health, which allows individuals to make sense of their contexts and find meaning in life.

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.

The universal models employed by psychiatry de-emphasise the role of context and culture. Despite highlighting the impact of culture on psychiatric diagnosis and management in the Diagnostic and Statistical Manual of Mental Disorders-5, most of the changes suggested remain in the introduction and appendices of the manual. Nevertheless, clinical and biological heterogeneity within phenomenological categories mandates the need to individualise care. However, social and cultural context, patient beliefs about causation, impact, treatment and outcome expectations are never systematically elicited, as they were not essential to diagnosis and classification. Patient experience and narratives are trivialised and the biomedical model is considered universal and transcendental. The need to elicit patient perspectives, evaluate local reality, assess culture, educate patients about possible interventions, and negotiate a shared plan of management between patient and clinician is cardinal for success. The biopsychosocial model, which operates within a paternalistic physician-patient relationship, needs to move towards a shared approach, within a more equal patient-clinician partnership., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings., Methods and Findings: Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%-4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations., Conclusions: An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings-in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings.

The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychological interventions. This is necessary in all cultures and in every setting. Many schools of psychotherapy offer specific theories and particular techniques, yet they share many common approaches. Their individual techniques allow therapists form and structure to treat different clinical problems, discuss diverse content and use them in varied settings and among people with assorted cultural backgrounds. The heterogeneity within cultures, regions and populations demands that therapists understand the local and individual reality. The apparent contradictions between standard psychological therapies and their use across cultures, when viewed through a form-content framework, allow for matching strategies for specific individuals and their distress, and for choosing the best treatment options from a diverse therapeutic armamentarium. Psychotherapies are at their weakest when they attempt to provide explanations across cultures and are at their strongest when they are used as vehicles for engagement with patients. The challenge is to find a common psychotherapeutic language, which attempts to bridge the divide between the issues facing the patient and the armamentarium of the therapist. The form-content paradigm at least partly explains the complexity of the issues within psychotherapy. It also allows the therapist to move from the therapy-centric orientation of Western approaches to the patient-centric orientations required for success in psychological therapies., (Copyright © 2010 John Wiley & Sons, Ltd.)

While there is increasing evidence of an association between poor mental health and the experience of poverty and deprivation, the relationship is complex. We discuss the epidemiological data on mental illness among the different socio-economic groups, look at the cause -effect debate on poverty and mental illness and the nature of mental distress and disorders related to poverty. Issues related to individual versus area-based poverty, relative poverty and the impact of poverty on woman's and child mental health are presented. This review also addresses factors associated with poverty and the difficulties in the measurement of mental health and illness and levels/impact of poverty.

More than 85% of the world's population lives in 153 low-income and middle-income countries (LAMICs). Although country-level information on mental health systems has recently become available, it still has substantial gaps and inconsistencies. Most of these countries allocate very scarce financial resources and have grossly inadequate manpower and infrastructure for mental health. Many LAMICs also lack mental health policy and legislation to direct their mental health programmes and services, which is of particular concern in Africa and South East Asia. Different components of mental health systems seem to vary greatly, even in the same-income categories, with some countries having developed their mental health system despite their low-income levels. These examples need careful scrutiny to derive useful lessons. Furthermore, mental health resources in countries seem to be related as much to measures of general health as to economic and developmental indicators, arguing for improved prioritisation for mental health even in low-resource settings. Increased emphasis on mental health, improved resources, and enhanced monitoring of the situation in countries is called for to advance global mental health.

Background: Sustainable cost-effective interventions to improve psychiatric morbidity and quality of life among the elderly have not been systematically evaluated in developing countries., Method: The most vulnerable elderly living in Pennathur, Vellore district, India, in terms of socioeconomic status and social supports, were invited to participate in a day-care program. Baseline assessments were done using the Mini Mental Status Examination, the Revised Clinical Interview Schedule and the World Health Organisation Quality of Life- Bref. Follow-up assessment was done at 3 months on subjects who took part and those who refused., Results and Conclusions: Forty-one (16.4%) were invited to take part. Twenty subjects took part in the program while 21 refused. There was a significant reduction in psychiatric morbidity and improvement in quality of life scores at 3 months for subjects who attended the program. The improvement in quality of life persisted after adjusting for gender, socioeconomic status and baseline scores. Costing of the program suggests sustainability., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

Study Design: Cross sectional survey., Objective: To examine the nature and prevalence of common mental disorders among informal carers of people with Spinal Cord Injury (SCI) and the association with their leisure satisfaction., Setting: Christian Medical College, Vellore, Tamilnadu, India., Methods: A cross-sectional survey of informal carers of people SCI at the Department of Physical Medicine and Rehabilitation. Fifty-three informal carers of people with SCI were interviewed using the Revised Clinical Interview Schedule to assess psychiatric morbidity, and using the Leisure Satisfaction Scale to measure leisure and contentment. Data on carers with psychiatric morbidity were compared to those without common mental disorders using univariate and multivariate statistics., Results: Study reported a high morbidity (53%), with most consistent diagnoses of depression and anxiety. Carers who were spouses, women, currently married and those with lower education had greater psychiatric morbidity and lesser leisure satisfaction, even after adjusting for age and education using logistic/linear regression. Age, occupation, residence, socioeconomic status, type and duration of SCI were not associated with either morbidity or leisure satisfaction., Conclusion: Many carers of people with SCI suffer from psychiatric morbidity and also have low scores on leisure satisfaction.

The 12-item General Health Questionnaire (GHQ-12), increasingly used to screen for common mental disorders (CMD) in primary care, has been validated in different languages and cultures. However, the validity and usefulness of the Tamil version has not been established for use in the community. This article reports a study to validate the Tamil version of the GHQ-12 in a rural setting in southern India. The research found that 16.5% of people interviewed satisfied international criteria for CMD. However, the predictive value of the tool as a tool for screening was found to differ from that found in studies undertaken in a hospital setting. While screening instruments need to be validated in specific types of populations before being employed, such tests may be less useful in community surveys where the prevalence of common mental disorders is low. Strategies which artificially increase the prevalence of common mental disorders in the sample screened will improve the performance of the instrument.

Objective: To delineate concepts, categories, causes of common mental disorders (CMD) and their treatment as understood by traditional healers practicing in rural South India., Methods: Key informant interviews, focus group discussions and in-depth interviews with traditional and faith healers were conducted to identify concepts, causes, presentations and treatments for CMD. Patients attending clinics conducted by these healers were interviewed using the Tamil versions of the Revised Clinical Interview Schedule (CIS-R) and the Short Explanatory Model Interview (SEMI) in order to identify CMD and understand their explanatory models of illness respectively., Results: Different terms, concepts and treatments were used by traditional and faith healers. A total of 72 patients were interviewed using the CIS-R and the SEMI. Thirty (42.3%) satisfied the International Classification of Diseases-10 Primary Care Version criteria for CMD. Mixed anxiety depression was the most common diagnosis (40%)., Conclusions: An understanding of local patient perspectives of common mental disorders will allow modern medicine to provide culturally sensitive and locally acceptable health care.

Objective: To examine commonly held indigenous beliefs about mental illness, which often differ markedly from the biomedical models, among community health workers in rural South India., Method: Indigenous beliefs about chronic psychosis were elicited from community health workers. The Short Explanatory Model Interview formed the basis of the interview., Results: A variety of indigenous beliefs, which contradicted the biomedical model, were elicited. A significant proportion of health workers did not recognize chronic psychosis as a disease condition, believing that it was caused by black magic, evil spirits and poverty, and felt that doctors could not help., Conclusion: The results of the study suggest that training programmes should elicit and discuss local beliefs prior to the teaching of the biomedical model of mental disorders.

Objective: The study examined the nature and prevalence of and the factors associated with common mental disorders in primary care in Vellore, South India., Method: Consecutive attenders (N = 327) to a primary health care facility were recruited., Results: One hundred and eleven (33.9%) subjects satisfied criteria for common mental disorders. Depression was the common presentation (83.8%). Indicators of low socio-economic status (being in debt, inability to buy food, having less than three square meals per day) and illiteracy were significantly associated with caseness., Conclusions: Subjects with common mental disorders are commonly seen in primary health care settings. Illiteracy and poverty are associated with caseness. Primary health care research and policy needs to focus on common mental disorders.

Background: Patients with unexplained somatic symptoms are commonly seen in primary care. We assessed the explanatory models and common mental disorders in patients with unexplained somatic symptoms attending a primary care facility in a rural area of south India., Methods: One hundred consecutive patients diagnosed to have unexplained somatic symptoms attending a primary care facility were examined. The Tamil version of the Revised Clinical Interview Schedule was used to assess common mental disorders and the Tamil version of the Short Explanatory Model Interview was used to assess their explanatory models., Results: Ninety-eight patients thought that their problem was serious. Sixty-nine, 41 and 40 claimed that it affected their work, family and social lives, respectively. Forty-two of the patients believed in black magic. Forty-four patients satisfied the ICD-10 PC criteria for common mental disorders. Depression was the commonest diagnosis (63.6%). Patients with psychiatric diagnoses admitted to emotional problems (chi2 = 46.9; p < 0.001), and felt that their problems affected their family (chi2 = 38.5; p < 0.001), social life (chi2 = 28.6; p < 0.001) and work (chi2 = 34.4; p < 0.001). More patients who satisfied criteria for psychiatric diagnosis felt that their problems were moderate or very serious (chi2 = 21.5; p < 0.001) and they feared they might become disabled or die (chi2 = 12.2; p < 0.001). Psychiatric syndromes were significantly associated with belief in black magic (chi2 = 7.01; p < 0.01). These associations remained statstically significant after adjusting for age, gender, literacy and socioeconomic indices using logistic regression., Conclusion: The majority of patients held strong beliefs regarding the physical nature of their complaints, believed In the serious nature of the problem and feared disability or death. There is a need to elicit specific explanatory models regarding the nature of illness in patients who present with somatic symptoms without organic causes. Understanding the patient's perspectives is a prerequisite for providing the necessary treatment and to dispel fears.

Background: Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work., Method: The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness., Results: The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings., Conclusions: The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.

Women of Indian origin are said to have a lower rate of recognized common mental disorders and a higher frequency of consultation in primary care than white British. The aim of this study was to evaluate factors, including explanatory models (patient perspectives) of illness, associated with common mental disorders and with frequency of consultation among women of Indian origin in primary care. The investigation was conducted in a general practice in West London with a large Indian population. Consecutive woman attenders of Indian descent were screened with the General Health Questionnaire-12 to identify probable cases of psychiatric morbidity. 100 patients were interviewed with the Revised Clinical Interview Schedule (CIS-R), a specific tool for the diagnosis of common mental disorders, and the Short Explanatory Model Interview, which elicits the individual's conceptualization of his or her illness. Those patients who satisfied CIS-R criteria were classified as 'cases', the others as 'controls'. Common mental disorders were documented in 30% of patients. The general practitioner's diagnosis of common mental disorders had a sensitivity of 17% and a specificity of 91%. Individuals with common mental disorders had a higher frequency of consultation (P = 0.017), were less likely to see depression as an indication for medical intervention and were more likely to withhold some of their concerns from the general practitioner. Incorrect diagnosis by the GP was most likely to occur when patients did not disclose all their complaints. These associations were all statistically significant after adjustment for possible confounders by multiple linear and logistic regression. Women of Indian origin in this sample had rates of common mental disorders similar to those in other UK populations. Differing conceptualizations of common mental disorders may contribute to their underrecognition in women of Indian origin.

Background: Factor analysis has been employed to identify latent variables that are unifying constructs and that parsimoniously describe correlations among a related group of variables. Confirmatory factor analysis is used to test hypothesized factor structures for a set of variables; it can also, as in this paper be used to model data from two or more groups simultaneously to determine whether they have the same factor structure., Method: Non-psychotic psychiatric morbidity, elicited by the Revised Clinical Interview Schedule (CIS-R), from four culturally diverse populations was compared. Confirmatory factor analysis was employed to compare the factor structures of CIS-R data sets from Santiago, Harare, Rotherhithe and Ealing. These structures were compared with hypothetical one and two factor (depression-anxiety) models., Results: The models fitted well with the different data sets. The depression-anxiety model was marginally superior to the one factor model as judged by various statistical measures of fit. The two factors in depression-anxiety model were, however, highly correlated., Conclusions: The findings suggest that symptoms of emotional distress seem to have the same factor structure across cultures.

Background: The General Health Questionnaire (GHQ) has been validated in different languages and cultures and in diverse settings. However, the validity of the 12-item version, increasingly used for screening for psychiatric morbidity in primary care, has not been established among ethnic Indians living in the United Kingdom., Methods: The GHQ-12 was used to screen for psychiatric morbidity in a study of patterns of consultation and explanatory models of mental illness in a general practice in West London. All individuals who scored 2 or more and an equal number of individuals who scored 0 or 1 were interviewed using the Revised Clinical Interview Schedule (CIS-R) to confirm psychiatric morbidity. Hindi versions of the both these instruments were also employed. Thresholds of GHQ were compared against the standard of the CIS-R using the recommended threshold of 12 and above as indicating caseness. A receiver operator characteristic curve was drawn to obtain the best threshold value for screening., Results: The optimal threshold for screening as assessed by receiver operator characteristic analysis was 2/3. This threshold had a sensitivity of 96.7% and a specificity of 90%., Conclusions: The sensitivity and specificity of the 12-item General Health Questionnaire among women of ethnic Indian origin living in the United Kingdom is high. It can be employed as a screening instrument to identify individuals with psychiatric morbidity in this population.

The concurrent use of multiple psychotropic medication has been reported to be widely prevalent in the treatment of mental disorders, and is considered inferior practice [1]. However, the complexity of the issues demands reappraisal. This paper attempts to discuss the conceptual and practical issues involved.

The evidence for the etiological basis of mental disorders is insufficient and contradictory. Such a situation has at least partly arisen due to the inherent heterogeneity within the various clinical diagnostic categories. Syndrome sub-categorization employing biological variables is suggested as a first step in order to achieve etiological homogeneity.

Forty six subjects infected with the human immunodeficiency virus (HIV) were followed up, for recording psychiatric morbidity if any, before and after the information regarding their HIV status was revealed to them. Among these, four patients had the AIDS syndrome, while 42 individuals were HIV carriers. The pre-information morbidity in the AIDS group included two individuals who presented with delirium and one with an adjustment disorder. The psychiatric diagnosis among the HIV carriers revealed one patient with major depression, four with adjustment disorders and four with alcohol dependence syndrome. The additional morbidity after the diagnoses was revealed included major depression and adjustment disorders which could be managed by psychological intervention and counselling in most cases. The individual who developed major depression later, committed suicide. The study though preliminary in nature, suggests that it may be beneficial to include psychiatric management as part of the general care of individuals with HIV infection.