- Email: [email protected]
Global mental health and neuroscience: different synergies might be needed
Correspondence
Mental health is a specialty that still faces vast misconceptions. Worldwide, individuals with mental health problems are not uncommonly shackled in chains and neglected, with little dignity and denial of basic human rights. Even in the UK, stigma is still attached to mental illness, and research consistently suggests that both medical and non-medical individuals hold fundamentally incorrect ideas about the role of psychiatry.1 Psychiatry recruitment is proving difficult and thus interest in targeting medical students’ experience of psychiatry is increasing. Educational curricula are constrained by the amount of time available for educators to teach students. As a result, an inevitable compromise must be made in the dedication of time and effort between providing theoretical knowledge against practical exposure and the breadth of subject against the depth of each individual topic. The main task of medical schools is to ensure the competence and safety of each generation of graduates as they enter the medical profession. At present, the emphasis of psychiatric teaching at UK medical schools is on core pathologies and key presentations that will equip the students with the necessary skills to look after patients in their foundation years. Unfortunately, the time is not always there to explore the many varied opportunities that a career in psychiatry can bring, or its wider implications in the world. On Nov 1, 2014, a student-run conference entitled Mental Health: A Global Focus was held at Green Templeton College, University of Oxford, UK. The conference, aimed at medical students and junior doctors, was packed to capacity, suggesting a huge interest in mental health and its worldwide effect. As a result of this observation, some ask why such a clearly interesting topic does not www.thelancet.com/psychiatry Vol 2 June 2015
receive more than a cursory mention within the compulsory teaching curriculum. A key role of all educational institutions is to empower students to selfdirect their learning and to provide ample opportunities for students to explore and advance interests beyond a core curriculum. All UK medical schools offer elective periods that could be organised to allow experience of international issues in psychiatry first-hand. Furthermore, student initiatives such as the Oxford global mental health conference can usually be well supported by UK universities, Royal Colleges, and journals. As the (predominantly) student organisers of the Oxford conference, we have a clear interest in global mental health, which was compounded by the fascinating talks by eminent academics and clinicians. However, in each cohort of medical students, only a proportion will be interested in psychiatry or global health, or both. A smaller minority still will eventually choose to pursue a career in these specialities. At Oxford, the number of graduates who choose to specialise in psychiatry remains steady at roughly 4% every year. In view of this, it is perhaps appropriate that global mental health receives just a cursory mention within the
compulsory teaching curriculum, so long as opportunities and funding are available for furthering special interests. We declare no competing interests.
Veena Aggarwal, Rachel Patel, *Charlie D Zhou, Keith Hawton [email protected] Medical Sciences Division, University of Oxford, Oxford OX1 2JD, UK (VA, RP, CDZ); and Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK (KH) 1
Royal College of Psychiatrists. Misconceptions about psychiatrists ‘common’ among public and medical students. 2013. www.rcpsych.ac. uk/mediacentre/pressreleases2013/ psychiatristsrole.aspx (accessed April 28, 2015).
Global mental health and neuroscience: different synergies might be needed In the Lancet Psychiatry, Dan Stein and colleagues 1 correctly identify that synergies are needed in the specialties of global mental health and neuroscience; however, the synergies they propose might not lead to progress in the global understanding and treatment of mental disorders. Both the global mental health movement and the
Gombert, Sigrid/Science Photo Library
Education and global mental health
489
Correspondence
For ICD 10th revision see http://apps.who.int/ classifications/icd10/ browse/2015/en For DSM-5 see http://dsm.psychiatryonline.org/ For Research Domain Criteria project see http://www.nimh.nih.gov/ research-priorities/rdoc/index. shtml/
490
field of neuroscience should look elsewhere for synergies if they are to make tangible improvements to the wellbeing of the world. Although emotions such as sadness and worry are experienced globally, to extrapolate from this and conclude that diagnostic systems from developed countries, such as the ICD, the DSM, and the Research Domain Criteria project by the US National Institute of Mental Health, can be appropriately applied on a global scale is flawed logic and might produce serious consequences. Stein and colleagues 1 state that the DSM-5 “encourages a cultural formulation”, but seem not to realise that a DSM-based cultural formulation is still a doctrine from developed countries that might be imposed in a neocolonial way onto lower-income countries to usurp their beliefs and explanations. For example, Indigenous Australians regard the term mental health as inappropriate, and prefer the term social and emotional wellbeing instead. 2 This difference is not a semantic quibble, but suggests a different world view and a different way to understand and explain one aspect of human function that is completely disregarded when diagnostic systems from developed countries are imposed on developing countries or indigenous populations. One reason for the unacceptable disparity in wellbeing between Indigenous and non-Indigenous Australians might be because there is almost no acknowledgment or genuine embracement of Indigenous knowledge or culture. Greater progress in understanding the human emotions of distress and despair will be achieved only by the development of knowledge through authentic synergies between different cultural groups that sit at the table as equal contributors to the endeavour. As I have emphasised in a previous publication,3 the synergy that will be of greatest benefit to neuroscience
is the development of robust models of functioning that combine findings from the fields of neuroscience with knowledge of psychological and social functioning from all cultures. The experience of human distress will not be found in an isolated brain circuit, molecule, or biochemical profile. Distress, despair, and misery are problems of living; therefore, any research that is going to make a lasting contribution to our understanding and treatment of these events needs to be able to articulate the way in which the biological, psychological, and social elements are integrated to explain individual functioning. Synergies between mental health research and neuroscience are definitely needed to increase wellbeing in people on a global scale. The synergies recommended by Stein and colleagues, 1 however, are most likely to benefit researchers and practitioners in high-income countries, and the pharmaceutical industry. The synergies that will be of most benefit to citizens of the world will be those of knowledge between different cultures and of functioning between the biological, psychological, and social domains. I declare no competing interests.
Timothy A Carey Tim.Carey@flinders.edu.au Centre for Remote Health, PO Box 4066, Alice Springs, NT 0871, Australia 1
2
3
Stein DJ, He Y, Philips A, Sahakian BJ, Williams J, Patel V. Global mental health and neuroscience: potential synergies. Lancet Psychiatry 2015; 2: 178–85. Carey TA. A qualitative study of a social and emotional well-being service for a remote indigenous Australian community: implications for access, effectiveness, and sustainability. BMC Health Serv Res 2013; 13: 80. Carey TA. Mental health: integration is the key to the revolution. Lancet 2015; 382: 1403–04.
Authors’ reply We are grateful to Timothy Carey for providing us with an opportunity to clarify further our position on the synergies between global mental health and clinical neuroscience,
which we first discussed in our Series paper1 in the Lancet Psychiatry. Carey’s letter raises broad conceptual questions about the nature of psychiatric diagnosis and science. We have elsewhere characterised these conceptual debates in terms of classical, critical, and integrative approaches. 2,3 The classic position that psychiatric diagnoses carve nature at its joints, and are theory neutral and value free, is held by few in the disciplines of either global mental health or clinical neuroscience. 4 A critical position, which emphasises the sociocultural construction of diagnoses, has previously been used to critique global mental health,5 and is consistent with the emphasis from Carey on distress and despair as “problems of living”, on DSM as a doctrine from developed countries that is imposed in a neocolonial way on indigenous populations, and on the failure of mental health professionals to “genuinely embrace indigenous knowledges”. Our own position is an integrative one that attempts to steer a balanced course between scientism and scepticism. In our Series paper,1 we emphasise that “global mental health specialists and clinical neuroscientists are acutely aware of the limitations of present psychiatric classification systems”. However, we still maintain that such systems represent iterative attempts to maximise scientific validity and clinical usefulness,6 that revision processes have incorporated several perspectives including those from a range of professionals and consumers,7 and that we should be wary of expecting more from such systems than they can possibly deliver.8 Carey makes several more specific points. First, he notes the importance of social and emotional wellbeing. Certainly, researchers in both the disciplines of global mental health and clinical neuroscience are interested in not only disease but also wellbeing, and we would emphasise that work at the intersection of www.thelancet.com/psychiatry Vol 2 June 2015
Mental health is a specialty that still faces vast misconceptions. Worldwide, individuals with mental health problems are not uncommonly shackled in chains and neglected, with little dignity and denial of basic human rights. Even in the UK, stigma is still attached to mental illness, and research consistently suggests that both medical and non-medical individuals hold fundamentally incorrect ideas about the role of psychiatry.1 Psychiatry recruitment is proving difficult and thus interest in targeting medical students’ experience of psychiatry is increasing. Educational curricula are constrained by the amount of time available for educators to teach students. As a result, an inevitable compromise must be made in the dedication of time and effort between providing theoretical knowledge against practical exposure and the breadth of subject against the depth of each individual topic. The main task of medical schools is to ensure the competence and safety of each generation of graduates as they enter the medical profession. At present, the emphasis of psychiatric teaching at UK medical schools is on core pathologies and key presentations that will equip the students with the necessary skills to look after patients in their foundation years. Unfortunately, the time is not always there to explore the many varied opportunities that a career in psychiatry can bring, or its wider implications in the world. On Nov 1, 2014, a student-run conference entitled Mental Health: A Global Focus was held at Green Templeton College, University of Oxford, UK. The conference, aimed at medical students and junior doctors, was packed to capacity, suggesting a huge interest in mental health and its worldwide effect. As a result of this observation, some ask why such a clearly interesting topic does not www.thelancet.com/psychiatry Vol 2 June 2015
receive more than a cursory mention within the compulsory teaching curriculum. A key role of all educational institutions is to empower students to selfdirect their learning and to provide ample opportunities for students to explore and advance interests beyond a core curriculum. All UK medical schools offer elective periods that could be organised to allow experience of international issues in psychiatry first-hand. Furthermore, student initiatives such as the Oxford global mental health conference can usually be well supported by UK universities, Royal Colleges, and journals. As the (predominantly) student organisers of the Oxford conference, we have a clear interest in global mental health, which was compounded by the fascinating talks by eminent academics and clinicians. However, in each cohort of medical students, only a proportion will be interested in psychiatry or global health, or both. A smaller minority still will eventually choose to pursue a career in these specialities. At Oxford, the number of graduates who choose to specialise in psychiatry remains steady at roughly 4% every year. In view of this, it is perhaps appropriate that global mental health receives just a cursory mention within the
compulsory teaching curriculum, so long as opportunities and funding are available for furthering special interests. We declare no competing interests.
Veena Aggarwal, Rachel Patel, *Charlie D Zhou, Keith Hawton [email protected] Medical Sciences Division, University of Oxford, Oxford OX1 2JD, UK (VA, RP, CDZ); and Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK (KH) 1
Royal College of Psychiatrists. Misconceptions about psychiatrists ‘common’ among public and medical students. 2013. www.rcpsych.ac. uk/mediacentre/pressreleases2013/ psychiatristsrole.aspx (accessed April 28, 2015).
Global mental health and neuroscience: different synergies might be needed In the Lancet Psychiatry, Dan Stein and colleagues 1 correctly identify that synergies are needed in the specialties of global mental health and neuroscience; however, the synergies they propose might not lead to progress in the global understanding and treatment of mental disorders. Both the global mental health movement and the
Gombert, Sigrid/Science Photo Library
Education and global mental health
489
Correspondence
For ICD 10th revision see http://apps.who.int/ classifications/icd10/ browse/2015/en For DSM-5 see http://dsm.psychiatryonline.org/ For Research Domain Criteria project see http://www.nimh.nih.gov/ research-priorities/rdoc/index. shtml/
490
field of neuroscience should look elsewhere for synergies if they are to make tangible improvements to the wellbeing of the world. Although emotions such as sadness and worry are experienced globally, to extrapolate from this and conclude that diagnostic systems from developed countries, such as the ICD, the DSM, and the Research Domain Criteria project by the US National Institute of Mental Health, can be appropriately applied on a global scale is flawed logic and might produce serious consequences. Stein and colleagues 1 state that the DSM-5 “encourages a cultural formulation”, but seem not to realise that a DSM-based cultural formulation is still a doctrine from developed countries that might be imposed in a neocolonial way onto lower-income countries to usurp their beliefs and explanations. For example, Indigenous Australians regard the term mental health as inappropriate, and prefer the term social and emotional wellbeing instead. 2 This difference is not a semantic quibble, but suggests a different world view and a different way to understand and explain one aspect of human function that is completely disregarded when diagnostic systems from developed countries are imposed on developing countries or indigenous populations. One reason for the unacceptable disparity in wellbeing between Indigenous and non-Indigenous Australians might be because there is almost no acknowledgment or genuine embracement of Indigenous knowledge or culture. Greater progress in understanding the human emotions of distress and despair will be achieved only by the development of knowledge through authentic synergies between different cultural groups that sit at the table as equal contributors to the endeavour. As I have emphasised in a previous publication,3 the synergy that will be of greatest benefit to neuroscience
is the development of robust models of functioning that combine findings from the fields of neuroscience with knowledge of psychological and social functioning from all cultures. The experience of human distress will not be found in an isolated brain circuit, molecule, or biochemical profile. Distress, despair, and misery are problems of living; therefore, any research that is going to make a lasting contribution to our understanding and treatment of these events needs to be able to articulate the way in which the biological, psychological, and social elements are integrated to explain individual functioning. Synergies between mental health research and neuroscience are definitely needed to increase wellbeing in people on a global scale. The synergies recommended by Stein and colleagues, 1 however, are most likely to benefit researchers and practitioners in high-income countries, and the pharmaceutical industry. The synergies that will be of most benefit to citizens of the world will be those of knowledge between different cultures and of functioning between the biological, psychological, and social domains. I declare no competing interests.
Timothy A Carey Tim.Carey@flinders.edu.au Centre for Remote Health, PO Box 4066, Alice Springs, NT 0871, Australia 1
2
3
Stein DJ, He Y, Philips A, Sahakian BJ, Williams J, Patel V. Global mental health and neuroscience: potential synergies. Lancet Psychiatry 2015; 2: 178–85. Carey TA. A qualitative study of a social and emotional well-being service for a remote indigenous Australian community: implications for access, effectiveness, and sustainability. BMC Health Serv Res 2013; 13: 80. Carey TA. Mental health: integration is the key to the revolution. Lancet 2015; 382: 1403–04.
Authors’ reply We are grateful to Timothy Carey for providing us with an opportunity to clarify further our position on the synergies between global mental health and clinical neuroscience,
which we first discussed in our Series paper1 in the Lancet Psychiatry. Carey’s letter raises broad conceptual questions about the nature of psychiatric diagnosis and science. We have elsewhere characterised these conceptual debates in terms of classical, critical, and integrative approaches. 2,3 The classic position that psychiatric diagnoses carve nature at its joints, and are theory neutral and value free, is held by few in the disciplines of either global mental health or clinical neuroscience. 4 A critical position, which emphasises the sociocultural construction of diagnoses, has previously been used to critique global mental health,5 and is consistent with the emphasis from Carey on distress and despair as “problems of living”, on DSM as a doctrine from developed countries that is imposed in a neocolonial way on indigenous populations, and on the failure of mental health professionals to “genuinely embrace indigenous knowledges”. Our own position is an integrative one that attempts to steer a balanced course between scientism and scepticism. In our Series paper,1 we emphasise that “global mental health specialists and clinical neuroscientists are acutely aware of the limitations of present psychiatric classification systems”. However, we still maintain that such systems represent iterative attempts to maximise scientific validity and clinical usefulness,6 that revision processes have incorporated several perspectives including those from a range of professionals and consumers,7 and that we should be wary of expecting more from such systems than they can possibly deliver.8 Carey makes several more specific points. First, he notes the importance of social and emotional wellbeing. Certainly, researchers in both the disciplines of global mental health and clinical neuroscience are interested in not only disease but also wellbeing, and we would emphasise that work at the intersection of www.thelancet.com/psychiatry Vol 2 June 2015