BULLETIN of the NETHERLANDS SOCIETY for TROPICAL MEDICINE and INTERNATIONAL HEALTH

N O 0 4 / d e c e m b e r 2 0 2 0 - v o l u m e 5 8

GLOBAL MENTAL HEALTH EDITORIAL

THERE IS NO HEALTH WITHOUT MENTAL HEALTH

nited Nations Secretary- MHPSS is at the top of the Netherlands’ General António Guterres international development agenda. rightly reiterated this We are fully committed to an MHPSS- CONTENT simple but powerful mes- inclusive approach in humanitarian Usage in May 2020, when Covid-19 had as well as conflict-prevention and EDITORIAL - 2 been with us for only a few months. peacebuilding efforts. We promote Mental health and psychosocial support and ensure this through international REVIEWS (MHPSS) are vital for our individual political and diplomatic efforts, through Psychosocial rehabilitation: and collective well-being, particularly policy dialogue with our partners, a global perspective - 3 in these disturbing Covid-19 times. and by supporting a number of initia- Indeed, MHPSS is a powerful tool tives to facilitate MHPSS-inclusive Collaboration between to unlock our human resilience and responses in humanitarian and traditional healers and strengthen human capital. This is even peacebuilding work on the ground. psychiatrists to improve care more crucial for the most vulnerable for people with psychotic people hit by conflict or disaster. The e therefore very much welcome disorders - 5 Netherlands therefore strongly advocates Wthis special edition of MTb recognising the importance of MHPSS dedicated to global MHPSS, and are Stigma, schizophrenia, suicide: for people and communities affected by grateful to its guest editors Rembrant a global perspective - 7 crisis. We work hard to promote integra- Aarts and Hans Rode for bringing tion of MHPSS into all crisis response together such a varied pool of authors Mental health and psychosocial from the very beginning. We encourage with varied expertise in the field, both support: hidden potential and integrating basic psychosocial skills academically and on the ground. This harm - 10 into the training of every humanitarian issue of MTb is an excellent gateway worker. Finally, we stress the impor- to disseminate a rich body of knowl- Mental health care in tance of attending to the psychosocial edge and expertise that is needed so Cambodia: history, status and a well-being of humanitarian staff, first urgently. After all, MHPSS helps to personal report - 12 responders and volunteers themselves. keep our minds and societies at peace.

Art aimed at understanding the These principles are high on the agenda Paul Bekkers mentally ill - 15 of the MHPSS Reference Group[1], which Special Envoy Mental health and psychoso- is part of the Inter-Agency Standing cial support CONSULT ONLINE Committee, the longest-standing and Ministry of Foreign Affairs, the Netherlands Anxiety disorder in Accra, highest-level humanitarian coordina- Ghana - 17 tion forum of the UN. They are also reflected in the December 2019 resolu- 1. Inter-Agency Standing Group [Internet]. IASC Reference Group on Mental Health and Psychosocial Support [2] BOOK REVIEW tion on MHPSS of the International in Emergency Settings; [accessed 8 December 2020]. Available from: https://interagencystandingcommittee. Een goede geest bestaat niet Red Cross and Red Crescent Movement, org/iasc-reference-group-on-mental-health-and- - 19 which endeavours to provide staff and psychosocial-support-in-emergency-settings 2. International Conference of the Red Cross and Red volunteers with the necessary skills to Crescent [Internet]. Resolution addressing mental health and psychosocial needs of people affected ANNOUNCEMENT recognise and respond to psychosocial by armed conflicts, natural disasters and other More global mental health in needs. Staff and volunteers are often emergencies, adopted at the 33rd International Conference, Geneva, 9-12 December 2019; [accessed the upcoming NVTG symposium rooted in the communities they serve, 8 December 2020]. Available from: https:// rcrcconference.org/app/uploads/2019/12/33IC- and webinar - 20 giving them unique access to these R2-MHPSS-_CLEAN_ADOPTED_en.pdf communities as well as knowledge of local context and dynamics. Not only is MHPSS crucial at the individual level, it is also needed and effective at the community level. It helps individuals, ‘THERE IS families, and communities to release NO HEALTH their potential to recover, maintain or WITHOUT regain their resilience and perspec- MENTAL tive, rebuild social cohesion, resume livelihoods, and foster reconciliation. HEALTH’

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Psychosocial rehabilitation: a global perspective

ore than half a billion PSYCHOSOCIAL REHABILITATION­ part in the lives of African people.In people worldwide suffer IN LMICS rural Ethiopia, only 10% of people with from neuropsychiat- In most LMICs, mental illness carries schizophrenia have access to biomedi- ric disorders. The vast a stigma that is just as debilitating as in cal care, a treatment gap largely due to Mmajority of these individuals live developed countries. The labelling of an an inadequate number of mental health in Africa, Asia and Latin America. individual as ‘mentally ill’ is associated specialists.[5] The Gefersa Mental Health Most of these persons lack access with important social consequences Rehabilitation Center near Addis Ababa to appropriate treatment or care, within the community and among is the only Ethiopian facility that exclu- and many are subject to stigma, relatives, friends, neighbours and sively provides PSR services for individ- discrimination and marginalisation. employers, and this hinders the process uals with severe mental disorders. This This adds up to a serious psycholog- of recovery. Because of non-existent or facility is largely inaccessible to most ical, physical, social and economic very rudimentary health insurance and patients who live hundreds of miles burden. Neuropsychiatric disorders social welfare, individuals with mental away in rural areas, making the estab- can lead to chronic disability and illness in LMICs are often economi- lishment of similar facilities for severely therefore represent an important cally dependent on their families. When affected patients living in different health issue across the globe.[1] doing PSR, one has to be aware of the regions essential through large financial Although there are effective and local system and other conditions, and investment for infrastructure develop- inexpensive treatments for many not necessarily assume support from ment and trained manpower. The prom- neuropsychiatric illnesses, most intact extended families. In many cases, ising results of a pilot study of a trained patients in low- and middle-income growing urbanisation in developing lay workers’ community-based reha- countries (LMICs) are deprived of countries means that the extended bilitation intervention for people with treatment and psychosocial reha- family system is fast disappearing.[3] schizophrenia present a realistic model bilitation. Ultimately, the burden of For at least 80% of rural inhabitants in of PSR for most patients in LMICs.[6] It mental illness, in terms of suffer- LMICs, traditional healers are the main is important to note that such models ing and monetary costs, is high for source of help for people with mental are feasible in LMICs as they do not patients and their families.[2] disorders.[2] Based on our own clinical require expensive infrastructures and experience and observations in LMICs, can be delivered by trained lay workers. PSYCHOSOCIAL REHABILITATION patients with severe neuropsychiatric Psychosocial rehabilitation (PSR) is a disorders do not improve by resorting A successful community-oriented reha- process of restoring well-being, and only to traditional treatment options; bilitation programme for persons with social and occupational functioning they usually need neuroleptic, antide- chronic schizophrenia was developed affected by mental or emotional disor- pressant or antiepileptic medication. in Malaysia in 1978. It prepares indi- ders. Although PSR was long neglected viduals with chronic schizophrenia for as an intervention, it has gained wider COUNTRY-SPECIFIC EXAMPLES gainful employment in the community: recognition in the last decades. The The first attempt to establish commu- in a follow-up analysis seventeen years establishment of the World Association nity-oriented treatment and rehabilita- later, 56% of patients had spent five or for Psychosocial Rehabilitation (WAPR) tion in Africa was in 1954 by Thomas more years making their own living in in 1986, with the mission to strengthen Adeoye Lambo,[4] who developed the their original community settings.[7] rehabilitation worldwide, marked an Aro Village system in Nigeria. Briefly, important milestone. Besides mental Lambo’s aim was to integrate the In India there is a large PSR gap health professionals, patients, family traditional village community with largely due to the shortage of special- members and voluntary organisations traditional healers and modern psy- ist mental health care. Thanks to the are also involved in WAPR activities chiatry, by offering patients modern involvement of NGOs, there are some (www.wapr.org). Over the years, PSR psychiatric care locally, within a familiar outstanding examples of PSR in India has made its way from institutions into social environment. Lambo stressed such as Jyothi Nivas in Kerala. Besides communities, taking account of specific that the strength of this approach was good PSR, it provides innovative anti- regional, historic, economic, social and grounded in the resources available in stigma campaigns for the surround- cultural factors. Our discussion of reha- the village community such as flexibility ing communities. Another successful bilitation in this article will refer pri- and tolerance. An important element PSR programme is Chittadhama, a marily to patients with schizophrenia, of this approach was recognition of the rehabilitation and residential centre since this group forms more than half therapeutic value of the traditional cults, for homeless persons with mental of patients with severe mental illness dances and rituals that played (and to illness, in the state of Karnataka.[8] undergoing long-term hospital care. a large extent still play) such a large

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Many of the issues raised above are not mental illness into the community, confined to LMICs and may, to some whether in low-, middle- or high- Wolfgang Krahl, MD, MA extent, apply to high-income countries income countries, is an essential Senior consultant psychiatrist, chair- as well. In 2017, Drake wrote, ‘The component of mental health care. Any man of i.nez (International Network for central problem, however, is lack of efforts towards improvement of PSR Cooperation in Mental Health), Munich, access to high-quality services, even in services need to address stigma and Germany the wealthiest countries. In the USA, discrimination against psychiatric [email protected] for example, fewer than 5% of people patients since these will influence the with serious psychiatric disorders can implementation, reception and ulti- Markos Tesfaye, MD, PhD access evidence-based psychiatric reha- mate success of PSR programmes. Professor of psychiatry, Department of bilitation.’[9] Bond observed that ‘while Psychiatry, St. Paul’s Hospital Millennium the USA has led the way in develop- Medical College, Addis Ababa, Ethiopia ing, researching and disseminating Based on the authors’ personal expe­ [email protected] evidence-based psychiatric rehabilitation rience, the following conditions must services around the world, the quality of be met for the success of psychosocial Murali Thyloth, MB: BS, MD (Psy), DPM mental health treatment and rehabilita- rehabilitation in any setting: Professor and Head, Department of tion services in the USA lags behind 1. A positive attitude towards Psychiatry, Ramaiah Medical College, services in many other industrialised the chronic patient Bangalore, India, President, World nations.’[10] Thus, we need to be aware 2. Hope that a positive Association for Psychosocial Rehabilitation that research itself does not necessar- outcome can be achieved [email protected] ily guarantee implementation of good 3. A rehabilitative infrastructure PSR services. It requires appropriate 4. Rehabilitation that match Note: Since none of the authors policies and political will to provide the wishes and abilities of are native English speakers, they evidence-based PSR to those who need the individual patient are grateful to Osborne Almeida it. In fact, there are many creative PSR 5. Acceptance that for his suggestions and edits. programmes throughout the globe, but psychopathology per se does there is a scarcity of data to support their not hinder rehabilitation efficacy; this implies that there is scope 6. Providing neuroleptic medication REFERENCES for research on the short- and long-term where necessary and bearing 1. Petersen I. Comprehensive integrated primary mental health care for South Africa. Pipedream outcomes of such PSR programmes. in mind that this in itself in not or possibility? Soc Sci Med. 2000 Aug;51(3):321- sufficient for patients’ recovery 34. DOI: 10.1016/s0277-9536(99)00456-6 2. Addo R, Agyemang SA, Tozan Y, et al. Economic Innovative approaches such as ‘sup- 7. Recruitment of an interested burden of caregiving for persons with severe mental illness in sub-Saharan Africa: a systematic ported employment’ for people with and motivated staff review. PLoS One. 2018 Aug 9;13(8):e0199830. severe mental illness are available in 8. Due consideration of the DOI: 10.1371/journal.pone.0199830 3. Ong KL. The burden on the family of schizophrenic Europe. Supported employment is a context including local culture, patients [dissertation]. University of Malaya; 1995 4. Lambo A. The village of Aro. In: King M, editor. form of PSR wherein individuals recov- economy, health care system Medical care in developing countries: a primer ered from mental illness are assisted 9. Patience and perseverance ont medicine of poverty and a symposium from Makerere. Nairobi: Oxford University Press; 1966 to obtain and maintain a job. Even in 10. Continued efforts to demonstrate 5. Shibre T, Medhin G, Alem A, et al. Long-term clinical course and outcome of schizophrenia in Germany, where the unemployment to administrators, politicians, rural Ethiopia: 10-year follow-up of a population- rate is low, the chances of a person and even psychiatrists that based cohort. Schizophr Res. 2015 Feb;161(2– 3):414–20. DOI: 10.1016/j.schres.2014.10.053 who suffers from a severe psychiatric psychosocial rehabilitation works 6. Asher L, Hanlon C, Birhane R, et al. Community- based rehabilitation intervention for people with disorder finding suitable employment effectively to the advantage schizophrenia in Ethiopia (RISE): a 12 month mixed are slim. This prompted the found- of patients, their families methods pilot study. BMC Psychiatry. 2018 Aug 3;18(1):250. DOI: 10.1186/s12888-018-1818-4 ing of a social firm, the Irseer Kreis and community in general 7. Krahl W. Rehabilitation chronisch schizophrener Patienten in Malaysia. In: Hoffmann K, Machleidt Versand, in 1989 to provide protected W, editors. Psychiatrie im Kulturvergleich: Beiträge job opportunities for persons recovered des Symposiums 1994 des Referats Transkulturelle Psychiatrie der Deutschen Gesellschaft für from mental illness. This mail order Psychiatrie, Psychotherapie und Nervenheilkunde im Zentrum für Psychiatrie Reichenau. Berlin: Verlag company started with a staff of seven, Sadly, the current Covid-19 pandemic für Wissenschaft u. Bildung; 1997. p. 249-64 five of whom had recovered from a adds major challenges for the proper 8. Rao RS, Murali T, Mahadevaswamy M. Chittadhama: home for the homeless mentally ill [Internet]. [11] psychiatric disorder. Today (2020), the care of people with chronic diseases, WAPR BULLETIN. 2020 Mar:44;34-5 9. Drake RE. The future of psychiatric rehabilitation. company’s success can be measured by including neuropsychiatric illnesses. Epidemiol Psychiatr Sci. 2017 Jun;26(3):209- the fact that its workforce comprises 66 10. DOI: 10.1017/S2045796016000913 10. Bond GR, Drake RE. New directions for persons, fifty of whom are individuals psychiatric rehabilitation in the USA. Epidemiol Psychiatr Sci. 2017 Jun;26(3):26, 223–7. recovered from a psychiatric disorder. DOI: 10.1017/S2045796016000834 11. Krahl W, Müller W, Stöhr K. The role of social firms in psychosocial rehabilitation: Irseer Kreis CONCLUSION Versand: a successful example. VIIth World Congress World Association for Psychosocial Psychosocial rehabilitation aiming at Rehabilitation Paris, 7-10 May 2000 reintegrating persons with chronic

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Collaboration between traditional healers and psychiatrists to improve care for people with psychotic disorders

Across the globe, people with psychosis, receive care from THPs. The mentioned it was caused by a spell or the psychotic disorders remain at high majority of patients with schizophrenia devil. The supernatural causes indicated risk of being untreated, neglected perceive traditional medicine treat- varied widely and were aligned with and stigmatised. Worldwide, around ment to be effective for their condition, patients’ culture or religion.[8; unpublished data] 21 million people are affected with and high adherence rates to traditional schizophrenia, the most severe methods have been reported.[6] Recently, Suriname has a highly centralised psychotic disorder.[1] The illness has a randomized controlled trial was pub- health care sector with one psychi- an average global lifetime preva- lished by Gureje et al. (2020) showing atric hospital located in the capital, lence of 0.7%.[2] The global burden the effectiveness and cost-effectiveness Paramaribo, and one smaller outpa- of schizophrenia alone accounts for of collaboration between traditional tient clinic in the district Nickerie. 1.7% of all years lived with dis- and faith healers and primary health THPs in the country include herbal- abilities.[1] People with a diagnosis care providers in treating patients ists, Winti healers, Javanese healers, of schizophrenia live on average fif- with psychotic disorders in Ghana and and religious healers such as pandits teen years less than the background Nigeria.[7] In a collaborative care model, or imams; they have various ethnocul- population.[3] The highest burden is skills and advantages of THPs are fully tural backgrounds.[9] As healers, they found in low- and middle-income acknowledged, and cooperation between take on a special communal role as countries (LMICs),[1] where less than traditional health practitioners and the persons of trust and respect - a crucial a third of people with schizophrenia formal health care system exists. Prior feature for the detection and follow-up can access mental health care and to the study, both the primary health of psychotic episodes. THPs align with their life expectancy is shortest.[4] care providers and THPs were trained in the cultural and spiritual ideas people The course of psychotic disorders is psychosis, the collaborative care model, have on the origin and treatment of strongly determined by the social, and roles and responsibilities. Primary psychosis, are often located in nearby cultural and geographical context. health care providers were involved in settings, and are easy to access and Due to non-medical explanations medication prescription and psychoedu- consult. By visiting traditional healers as of mental health problems such as cation, while THPs applied traditional first line care, patients may experience supernatural causes and lack of re- practices such as herbs or rituals. People a delay in seeking health care in the sources - including limited number who received the intervention consisting formal health care system.[8; unpublished data] of psychiatrists, poor infrastructure, of collaborative care had better health and poor accessibility to the formal outcomes than those who received care We also explored the potential of health care system - many people as usual; they reported less disabilities, strengthening collaborative efforts with a psychotic disorder in LMICs a better course of illness, and increased between formal mental health care and remain undetected and untreated. capabilities to adjust to work.[7] THPs by interviewing traditional health It is a key challenge to improve practitioners.[10] Some of the traditional the lives of people with psychotic We describe two of our own experi- healers said they had a positive attitude disorders in low-resource settings ences exploring the role of tradi- towards collaboration, while some were and improve adverse social, political tional health practitioners in care for sceptical. The reasons for being sceptical and economic conditions. One way people with psychotic disorders. were mainly related to certain thoughts to move forward may be to estab- about the biomedical management, lish collaboration between formal EXPERIENCES IN SURINAME different attitudes and explanatory mental health care and the tradi- In Suriname, we explored how patients models on psychosis, and the lack of tional systems of medicine that are and their family members seek health acknowledgement of THPs by medical in place in most countries. care and the views and practices of and governmental bodies in Suriname. THPs with regard to psychosis. In our Interestingly, some form of referral COLLABORATIVE CARE first study, we found that the majority of system to general practitioners existed, Over the past years, the collaboration patients with a psychotic disorder and although not formalised. This feedback in mental health between traditional their family members consult a THP, as given by THPs should be trans- health practitioners (THPs) and the mainly as first line care.[8; unpublished data] ferred to the formal health care system, formal health care system has been Most of the patients and family mem- providing a perspective on traditional given attention.[5] Many patients with bers reported a supernatural explana- practices, and a possible basis for col- severe mental health problems, such as tion for the cause of psychosis and laboration. In designing our qualitative

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study and conducting these interviews, framework, it was possible to discover REFERENCES we discovered that health care profes- common ground during focus group 1. Charlson FJ, Ferrari AJ, Santomauro DF, et al. Global epidemiology and burden of sionals in the formal system also need meetings and interviews, which allowed schizophrenia: findings from the Global Burden to become acquainted with traditional for developing a collaborative project of Disease Study 2016. Schizoph Bull. 2018 Oct 17;44(6):1195–1203. DOI: 10.1093/schbul/sby058 practices and to overcome certain bar- of screening and referral by THPs of 2. McGrath J, Saha S, Chant D, et al. Schizophrenia: a concise overview of incidence, prevalence, riers towards the non-formal system. individuals with suspected psychosis. and mortality. Epidemiol Rev. 2008;30, 67–76. DOI: 10.1093/epirev/mxn001 3. Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of EXPERIENCES IN SOUTH AFRICA CONCLUSION potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet In rural South Africa, traditional Since 1991, the World Health Psychiatry. 2017 Apr;4(4):295-301. DOI:10.1016/ health practitioners and faith healers Organization has been advocating for S2215-0366(17)30078-0 [Published correction] 4. Lora A, Kohn R, Levav I, et al. Service availability provide a major part of first line care proper use of traditional medicine to and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income for health problems. In a resource- achieve health for all. More recently countries. Bull World Health Organ. 2012 Jan limited setting in KwaZulu-Natal, we they stated that traditional and comple- 1;90(1):47–54B. DOI: 10.2471/BLT.11.089284 5. World Health Organization. WHO traditional started building a collaboration with mentary medicine can contribute medicine strategy: 2014–2023 [Internet]. Geneva: World Health Organization; 2013. 78 p. traditional healers. The THPs were significantly to achieve universal health Available from: https://www.who.int/medicines/ educated with case vignettes to identify coverage in global mental health.[12, 13] publications/traditional/trm_strategy14_23/en/ 6. Ojagbemi A, Gureje, O. The potential role of and refer patients with psychosis to our Studies like Gureje et al. (2020) and traditional medicine in the management of schizophrenia. Curr Psychiatry Rep. 2020 Oct study team investigating the incidence, our own initiatives can contribute to 22;22(12):71. DOI: 10.1007/s11920-020-01196-7 early course, and treatment pathways this movement. Our experiences in 7. Gureje O, Appiah-Poku J, Bello T, et al. Effect of collaborative care between traditional and faith healers of psychotic disorders in this context. Suriname and South Africa, which and primary health-care workers on psychosis outcomes [11] in Nigeria and Ghana (COSIMPO): a cluster randomised The collaboration was optimised by have highly decentralised health care controlled trial. Lancet. 2020 Aug 29;396(10251):612- applying a culturally sensitive approach systems, make it clear that extra atten- 22. DOI:10.1016/S0140-6736(20)30634-6 8. Van Beek A, De Zeeuw J, De Leeuw M, et al. with support from local traditional tion is needed to overcome distance Duration of untreated psychosis and pathways to care in Suriname: a qualitative study among patients, as well as professional authorities. between the THPs and formal health relatives and general practitioners. Unpublished care system. The role of THPs in 9. Van der Meulen R. De schaduw van de winti. University of Amsterdam; 2008. As a first step, meetings were organised mental health care cannot be ignored, 10. Osmers A, Patsea M, Djordevic. An explorative study on traditional and complementary medicine with tribal counsellors, followed by a and lessons learned from previous as practitioners’ profile and their views and practices presentation of the study to the senior well as our own studies deserve atten- on psychosis in Suriname. Bachelorproject 2020 under supervision of Janine de Zeeuw, traditional chief of the region and the tion in designing collaborative care Randhir Nanda, Wim Veling. Unpublished 11. Veling W, Burns JK, Makhathini EM, et al. traditional council to which THPs are models that align with local infra- Identification of patients with recent-onset psychosis affiliated. As they saw the added value structure and health care systems. in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic of collaboration for THPs and their instruments. Soc Psychiatry Psychiatr Epidemiol. 2019 Mar;54(3):303–12. DOI: 10.1007/s00127-018-1623-x communities, a formal memorandum 12. World Health Assembly. Traditional medicine of understanding was signed and Janine de Zeeuw and modern health care: progress report by the Director-General. Geneva: World Health contact details of THPs provided. A Psychiatrist, Rijksuniversiteit Groningen, Organization; 1991. 44 p. Available from: https:// Community Research Advisory Board University Medical Center Groningen, apps.who.int/iris/handle/10665/173745 was established, providing feedback the Netherlands Reference 13 World Health Organization. WHO global report on traditional research procedures in relation to the [email protected] and complementary medicine. Geneva: World Health social and cultural values and beliefs Organization; 2019. 228 p. Available from: https://www. who.int/traditional-complementary-integrative-medicine of study participants and the wider Radnir Nanda WhoGlobalReportOnTraditionalAndComplementaryMedicine2019.pdf community. Finally, semi-structured Pyschiatrist, Psychiatrisch Centrum interviews and multiple focus group Suriname, Paramaribo, Suriname meetings with THPs were held. Symptoms of psychosis, help-seeking Wim Veling behaviours of (caregivers of) indi- Psychiater, Rijksuniversiteit Groningen, viduals with symptoms, experience University Medical Center Groningen, regarding referrals and subsequent the Netherlands treatment outcomes, personal beliefs on causes of mental illness, and treatment practices were extensively discussed. The collaborative approach demanded sufficient time to build mutual trust and acknowledgement of each other’s skills and practices. Whereas the worldview of THPs and their recogni- tion of causes of mental health prob- lems (e.g., displeasure of ancestors) differ from a biomedical psychiatric

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Stigma, schizophrenia, suicide: a global perspective

In old Greek, the word στίγμα (stig- that, in order to avoid stigma, persons analysed, 41% had objectifiable psychiat- ma) had the meaning of ‘brand, to infected with HIV became secretive ric symptoms.[7] Surprisingly, more than be branded, to be marked’. Over the and, rather than seeking medical advice, half the people with suicidal ideations ages up till our time it has evolved devoted themselves to spirituality. were not receiving psychological treat- into a mark of disgrace, associated However, if they were able to accept ment, and their suicidal thoughts were with a particular circumstance, the reality of the situation, they could not in themselves linked to a manifest quality or person. Stigma plays an become proud bearers of the term ‘liv- psychiatric disorder. It can be assumed important role in mental health, as ing with HIV’, supporting themselves that 113 Zelfmoordpreventie has also it influences the way psychiatric and others in self-help groups[6] - thus, worked in several ways to reduce stigma. patients are perceived by the gener- reducing internal stigma and, by open- First, due to the anonymity guaranteed al population and how patients see ing up to the community as a whole, to users, the role of internal stigma was themselves.[1] It is interesting to see hopefully reducing social stigma. reduced. Secondly, spearheading a cam- how stigma relates to or interacts paign to bring the problem of suicide with schizophrenia, and suicide. For into the open also reduced social stigma. this reason a PubMed search was conducted in 2018 with the terms In my initial search, 597 publications ‘stigma’, ‘schizophrenia’ and ‘sui- addressed both stigma and suicide. cide’. This resulted in large numbers Carpiniello and Pina came to the follow- of published articles: stigma 20,522, ing conclusions: ‘self-stigma’ develops in schizophrenia 134,032 and suicide a person having committed one or sev- 78,827. I will discuss the interaction eral suicide attempts and in the relatives between these three conditions.* of this person; ‘social stigma’ exists in the community towards suicidal persons STIGMA AND HEALTH** and in the community towards relatives Extensive research has been done on of those having committed suicide.[8] stigma in relation with leprosy and with HIV/Aids, both communicable diseases. Their findings are supported by Moore Nsaga et al. (2011) found that the more et al., who found that ‘inmates face people were affected within the commu- many hardships once they are released nity, the smaller the stigma, present and into the community and are being perceived.[2] This probably means that stigmatized. Being an ex-offender is the ‘social stigma’ was small. Social or often found to be a major barrier to external stigma is different from inter- Figure 1. Jewish woman (cc- Bundesarchiv). successful community reintegration.’[9] nal stigma, which eats away at people’s self-esteem and self-efficacy. The Jewish STIGMA AND SCHIZOPHRENIA woman wearing a yellow star (Figure 1) STIGMA AND SUICIDE In my search, 1,065 publications will initially have suffered from social Both social and internal stigma have addressed both stigma and schizo- stigma, but later on this might have been associated with suicide and suicide phrenia. Two of those publications are evolved into internal stigma, had she attempts. Every year approximately especially interesting for our purpose. been given the time to live.[3,4] Prisoners 100,000 people in the Netherlands Assefa et al., from Addis Ababa, use in orange overalls are stigmatised by attempt to end their lives; in 2019 sui- ‘experienced stigma’ and ‘internalized those orange overalls, social stigmata, cide attempts totalled 1,811. To help peo- stigma’ as their parameters.[10] These which, depending on the duration of ple considering suicide and to avert the are comparable to social and internal their imprisonment might or might fatal outcome, a programme was started stigma respectively. In a group of 212 not evolve into self-stigma. Then again, in 2009 by the late Jan Mokkenstorm. patients, using the diagnosis of schizo- within the prison walls, as in a ghetto, In April and May 2013 alone, 1,732 phrenia via an Amharic version of the stigma will be less. Research in the field people contacted 113 Zelfmoordpreventie Internalized Stigma of Mental Illness of HIV/AIDS has shown that, because (Suicide prevention), an emergency (ISMI) scale, they found a 50% to 72% of the already existing social stigma, telephone number and online service range of internalized stigma. They internal stigma plays an important role that was initiated just one year after also found that the level of internalized resulting in persons hiding the fact that the programme had started. It turned stigma in patients with schizophrenia they are infected. Mhode et al. describe out that 46% of those seeking contact was comparable to internal stigma in another form of stigma: ‘anticipated were receiving psychological treatment, European patients with schizophrenia. stigma’.[5] In Dar es Salaam, they found and when the content of the chats was [11] Factors associated with a higher

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level of internalized stigma were: rural residence, single marital status, and prominent psychotic symptoms.

In Istanbul, Ücok et al. interviewed 103 stable outpatients with schizophrenia and found that a low level of symptoms­ correlated with a lower degree of ­anticipated stigma at school or work.[12] If more pronounced symptoms were present, the opposite was true.

SCHIZOPHRENIA AND SUICIDE

Of the 2014 publications addressing Figure 2. Numbers of publications on stigma, schizophrenia and suicide. schizophrenia and suicide in my search, I will discuss just one. Cassidy et al. (2018) published a meta-analysis on risk factors for suicidality in patients with stigma schizophrenia. They conclude that ‘sui- cidal ideation’ is related with high scores on BDI and HAM-D, a high score on PANSS, and a greater number of psychi- atric hospitalizations; ‘suicide attempt’ self-esteem compliance is associated with hopelessness, history of depression, history of attempted suicide, family history of psychiatric illness, family history of suicide, being symptoms white, and history of addiction; ‘suicide’ is more frequent with shorter illness suicidal ideation length, younger age, and higher IQ.[13]

STIGMA, SCHIZOPHRENIA,­ AND SUICIDE*** Figure 3. Relationship between increased stigma and suicidal ideation. Of all the articles sampled in my search, only 38 addressed stigma and how can we stop going in circles and stigma can interrupt the vicious circle. schizophrenia and suicide. From the six reduce dramatic outcomes? We can treat This would be in line with the advice of publications listed in Table 1 and their psychosis and we can reduce suicide by Shrivastava et al, who state that stigma main conclusions, one may conclude addressing the topic candidly with our needs to be assessed during routine that, worldwide and across cultures, patients. Stigma however is not always clinical examination, and subjected to the interaction between stigma, considered during patient consulta- further research in order to develop schizophrenia and suicide is impor- tions. Recognising and discussing measurable objective criteria and tant and significant (Figure 2 and 3). Collett N, Pugh K, et al. United Kingdom 2015 A paper by Shrivashtava et al. on a Marked negative self-cognitions and high levels of suicidal ideations in patients with study in Toronto sums up the dilem- ­persecutory delusions mas health workers face when working Stip E, Caron J, et al. Canada 2017 with people suffering from schizophre- nia.[14] They found that stigma delays Perceived cognitive dysfunction and stigmatisation contribute to the onset of suicidal ideation treatment seeking, worsens course of Yoo, Kim, et al. South Korea 2015 burden and outcome, reduces compli- Low self-esteem closely related to suicidal ideation ance, and increases the risk of relapse. Lien YJ, Chang HA, et al. Taiwan 2017 Positive correlation between low self-esteem, insight and suicidal attempts DISCUSSION Touriño R, Acosta FJ, et al. Spain 2018 Psychiatrists in their daily work often find that patients with schizophrenia, Association between internalised stigma, higher hopelessness, depression and higher suicidality experiencing stigma and considering Sharaf AI, Ossman LH, et al. Egypt 2012 suicide, find themselves in a vicious Internalised stigma and depression independently predicted suicide risk circle. The question arises: where and Table 1: Publications on stigma and schizophrenia and suicide and their main conclusions.

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on antiretroviral therapy in Dar es Salaam: a assess whether treatment can reduce AUTHOR’S REMARKS qualitative perspective. AIDS Res and Treat. [14] 2016;2016:7925052. DOI: 10.1155/2016/7925052 the effects of stigma on patients. * In the literature different forms 6. Casale M, Boyes M, Pantelic M, et al. Suicidal of stigma are mentioned: social, thoughts and behaviour among South African adolescents living with HIV: can social support CONCLUSION external, internal, and anticipated buffer the impact of stigma? J Affect Disord. 2019 Feb 15;245:82-90. DOI: 10.1016/j.jad.2018.10.102 In the interest of patients diagnosed stigma, to name just a few. For our 7. Mokkenstorm JK First two year results at with schizophrenia and their relatives, purpose the dichotomy between ESSSB14 Tel Aviv sept 2012 [presentation]. 2012. Available from: https://www.slideshare.net/ stigma and suicidal thoughts need social and internal suffices mokkenstorm/113-online-suicide-prevention 8. Carpiniello B, Pinna F. The reciprocal relationship to be discussed as part of treatment between suicidality and stigma. Front Psychiatry. and care. One might ask, ‘Where do ** Social stigma is the societal disap- 2017 Mar 8;8:35. DOI: 10.3389/fpsyt.2017.00035 9. Moore K, Stuewig J, Tangney J. Jail inmates’ we go from here; how can we reduce proval (or discontent) that a person or perceived and anticipated stigma: implications for post-release functioning. Self Identity. 2013 Jan stigma?’ A recent systematic review group perceives based on particular 1;12(5):527-47. DOI: 10.1080/15298868.2012.702425 by Clay et al. gives an overview of characteristics, and which some people 10. Assefa D, Shibre T, Asher L, et al. Internalized stigma among patients with schizophrenia in Ethiopia: a methods shown to be effective in use to distinguish them from other cross-sectional facility-based study. BMC Psychiatry. 2012 Dec 29;12:239. DOI: 10.1186/1471-244X-12-239 low- and middle-income countries, members of a society. Stigma may 11. Brohan E, Elgie R, Sartorius N, et al. Self-stigma, including: health education and myth then be affixed to such persons, by empowerment and perceived discrimination among people with schizophrenia in 14 European countries: busting by using informal groups, society at large, as they seem to differ the GAMIAN-Europe study. Schizophr Res. 2010 [15] Sep;122(1-3):232-38. DOI: 10.1016/j.schres.2010.02.1065 broadcasting, and social media. from the mainstream cultural norms 12. Üçok A, Karadayı G, Emiroglu B, et al. Anticipated discrimination is related to symptom severity, functionality and quality of life in schizophrenia. *** BDI and HAM-D are scales Psychiatry Res. 2013 Oct 30;209 (3):333-9. DOI: 10.1016/j.psychres.2013.02.022 Rolf Vincent Schwarz, MD, PhD to rate depression; PANSS 13. Cassidy R, Yang F, Kapczinski F, et al. Risk factors Psychiatrist, former regional psychiatrist rates psychotic symptoms for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta- Kilimanjaro Region, former director of regression of 96 studies. Schizophr Bull. 2018 Jun 6;44(4):787-97. DOI: 10.1093/schbul/sbx131 training GGZ inGeest, freelance psychiatrist 14. Shrivastava A, Bureau Y, Rewari N, et al. at GGz Centraal REFERENCES Clinical risk of stigma and discrimination of mental illnesses: need for objective assessment [email protected] 1. Mutiso VN, Musyimi CW, Tomita A, et al. and quantification. Indian J Psychiatry. 2013 Epidemiological patterns of mental disorders and Apr;55(2):178–82. DOI: 10.4103/0019.5545.111459 stigma in a community household survey in urban slum 15. Clay J, Eaton J, Gronholm PC, et al. Core components and rural settings in Kenya. Int J Soc Psychiatry. 2018 of mental health stigma reduction interventions Mar;64(2):120-29. DOI: 10.1177/0020764017748180 in low- and middle-income countries: a systematic 2. Nsagha DS, Bamgboye EA, Nguedia Assob JC, et al. review. Epidemiol Psychiatr Sci. 2020 Sep Elimination of leprosy as a public health problem by 4;29:e164. DOI: 10.1017/S2045796020000797 2000 AD: an epidemiological perspective. Pan Afr Med J. 2011;9:4. DOI: 10.4314/pamj.v9i1.71176 3. Ultee W, Van Tubergen F, Luijkx R. The unwholesome theme of suicide. Forgotten statistics of attempted suicides in Amsterdam and jewish suicides in the Netherlands for 1936–1943. In: Brasz C, Kaplan Y, editors. Dutch jews as perceived by themselves and others. Leiden: Brill; 2001. p. 325–35 4. Levav I, Brunstein Klomek A. A review of epidemiologic studies on suicide before, during, and after the Holocaust. Psychiatry Res. 2018 Mar;261:35-9. DOI: 10.1016/j.psychres.2017.12.042 5. Mhode M, Nyamhanga T. Experiences and impact of stigma and discrimination among people

PHOTO NICK FOX (SHUTTERSTOCK)

DECEMBER 04 2020 MT BULLETIN OF NVTG 9 REVIEW

Mental health and psychosocial support: hidden potential and harm Towards understanding the unintended and intended social effects of mental health and psychosocial support interventions

n October 2019, Dutch an increased investment in (academic) causing harm as an unintended, but Minister for Foreign Trade and knowledge production on the function- nonetheless real, consequence must be Development Cooperation, Sigrid ing of MHPSS, as we currently lack considered and weighed from the outset’ Kaag, organised the International a comprehensive understanding of in all humanitarian interventions.[9] ConferenceI on Mental Health and these interventions, and in particular Psychosocial Support in Crisis of their positive (potential) and nega- Evaluations of interventions in the field Situations. Together with a coalition tive (harmful) longer-term effects. of international cooperation, how- of 28 countries and ten organisations, ever, often fail to analyse unintended she signed the Amsterdam Conference UNCOVERING UNINTENDED EFFECTS effects, and are therefore in need of Declaration, which pledges a commit- Both practitioners and academics have more appropriate methodologies, as ment to ‘look for opportunities to draw warned of the possible unintentional addressed by Koch and Schulpen in attention to mental health and psy- harm MHPSS interventions may cause the article Introduction to the special chosocial needs of people affected by to their recipients.[5] Following Shah, issue ­‘unintended effects of interna- emergencies’ and ‘to integrate and seek harm can be a direct consequence tional ­cooperation’.[10] Most evaluations opportunities to further scale up mental of MHPSS interventions not being exclusively focus on intended objec- health and psychosocial support’.[1] designed in a culturally appropriate tives and have a short-term design, This pledge resulted from the growing manner, resulting in several negative thereby neglecting unintended effects, attention for large unmet mental health consequences such as harm to psy- especially those which may only arise needs among people affected by disaster chological wellbeing and erosion of after a longer period of time. While and conflict. Although estimated rates community’s trust in MHPSS.[6] For the intended direct effects of MHPSS of mental disorder after conflict vary example, he described the case of com- interventions have been rigorously between contexts, a meta-analysis of batants in Sub-Saharan Africa for whom assessed by randomised control trials ‘methodologically stronger’ surveys conventional therapy would increase (RCTs), this method is known for its risk displays average prevalence rates distress, as they believe talking about of overlooking unanticipated outcomes. of 15-20% for depression and post- the people they killed invites angry [11] Yet, analysing unintended effects is traumatic stress disorder.[2] In contrast, spirits.[6] Adverse effects may also follow necessary to be able to plan the most only 0.3% of all development assistance from the interplay between context and adequate interventions and to mitigate for health was dedicated to mental intervention, when sources of stress the risk of doing harm. Unintended health between 2006 and 2016.[3] are left unaddressed and interventions effects can thus be negative, causing subsequently run the risk of being harm, but they can also be positive, At the conference, an important call negatively experienced as ‘irrelevant creating additional, unexpected benefits, for action was made to increase the or imposed’. [7] According to Miller and or even neutral.[12] Positive unintended available budget for mental health and Rasmussen, available data suggests effects are particularly underrepre- psychosocial support (MHPSS). MHPSS that ‘daily stressors’ (social and mate- sented in the literature,[10] which makes is the catch-all term for various interven- rial conditions such as poverty, family it more difficult to capitalise on them. tions addressing mental health needs, violence, unsafe housing, and social So there are lessons to be learned that ranging from psychotherapy to music isolation) cause mental health problems, can help further improve MHPSS. lessons. Policy makers and practitio- and therefore should be a priority in ners increasingly consider MHPSS to MHPSS.[8] If focus is limited to indi- WHAT ARE THE KNOWLEDGE GAPS? be a crucial element of humanitarian vidual psychological trauma resulting Our research team from Radboud aid. They further expect MHPSS to from conflict or other humanitarian University conducted a literature search have positive effects on political and emergencies, the collective experience between 1 July 2020 and 20 September socioeconomic goals such as ‘poverty is overlooked and people’s capacity to 2020 to get a first impression of which reduction, peacebuilding, address- recover is not strengthened.[7] Avoiding unintended effects of MHPSS interven- ing gender-based violence and [the] harm is a central point of attention tions have been described in academic reconstruction of affected areas and within the internationally recognised literature between 2011 and 2019.[13] economies’.[4] This article argues that the IASC Guidelines on mental health and Based on the reference lists of seven pledged commitment and call for more psychosocial support in emergency set- recently published systematic reviews funding should go hand-in-hand with tings, which state that ‘the potential for on MHPSS interventions in man-made

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and natural humanitarian emergency to reach a comprehensive understand- Together, these three steps form settings, our search revealed that only ing of the unintended and intended the basis of our research team’s twelve out of the 134 studies reported social effects of MHPSS. First, in order new approach, and can contrib- unintended effects. Out of these twelve to make claims about these effects, it ute to understanding MHPSS studies, eleven described an unan- is essential to follow participants in more comprehensively. ticipated negative change in symptoms MHPSS interventions over a longer related to mental health, and only one period of time. A longitudinal and CONCLUSION study reported a social unintended mixed-method research design will There is a need to deepen our under- effect. The studies included in our allow us to come to a more encompass- standing of the intended and unin- literature search had a strong focus on ing understanding of the (unintended) tended social effects of MHPSS direct and intended effects, namely consequences for people who have par- interventions. This requires a long-term, the possible improvement of mental ticipated in a MHPSS intervention, such multi-disciplinary approach, carried health. These findings suggest that as expanding a social network or finding out in multiple contexts and preferably unintended effects, which transcend the a job. Studying these long-term and focusing on psychosocial and multi- psychological and individual, are being social effects requires a multi-disciplin- domain interventions. Insights gained overlooked. The twelve unintended ary approach combining insights from can contribute to an advanced, more effects described above were all found psychology, anthropology and sociology. encompassing evaluation framework. in quantitative studies, which is likely Now is the right time to jump on related to the fact that most studies in Second, participants in MHPSS are the bandwagon, as MHPSS is receiv- the reference lists were quantitative often forcibly displaced as a result of ing increased attention and funding. (111 out of 134). Adding a qualitative humanitarian crises. They therefore There is great hidden potential in component may help detect other types move between places, and some may MHPSS to heal, but also to do harm. of unintended effects, through inductive resettle to a new country. Research This is why its effects, both intended analysis of MHPSS interventions.[11] should thus be carried out in mul- and unintended, positive and nega- tiple geographical contexts to fol- tive, deserve a more critical evaluation, Furthermore, Blanchet et al. have shown low people who have participated in and this requires investment from the in their systematic review that most of (perhaps multiple) MHPSS interven- academic and policy community. the attention is aimed at psychological tions. This will allow us to investigate interventions, and that the evidence-base the extent to which effects depend of psychosocial interventions is weaker, on contextual factors (e.g. the living Tessa Ubels although this type of intervention is conditions of a host country), and PhD candidate,Interuniversity Centre for most commonly practised.[14] Since many to analyse if MHPSS has effects on Social Science Theory and Methodology of the claims made to spur investments migration trajectories and integration. (ICS)/ Department of Anthropology and in MHPSS point to the social outcomes Development Studies, Radboud University, of these psychosocial interventions, it Third, special attention should be Nijmegen, the Netherlands is pivotal to research if these are true. given to psychosocial and multido- [email protected] main interventions. These interven- Finally, the evaluations of the included tions target mental health and social References and background information­ studies all considered short-term effects life domains simultaneously, such as about literature on page 18. only, and were conducted between safety and education at the family or two weeks and eight months after community level. The evidence base is the intervention took place. In this currently weaker for these interventions regard, we lack knowledge about the compared to psychological interven- long-term (socioeconomic) impact of tions. Psychosocial and multidomain MHPSS interventions for displaced interventions do however offer a pos- persons and the larger community. sible pathway to overcome the nega- tive effects of overlooking structural WAYS FORWARD problems and capitalise on positive A new research approach is required effects of mental health improvement.

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Mental health care in Cambodia: history, status and a personal report

For about forty years, the first au- century when the Khmer Empire cov- of Oslo in cooperation with Harvard thor (JvH) has been involved in the ered a large part of the region, including University for the training of 26 training and education of various Thailand, Laos, Vietnam and Malaysia. psychiatrists and 40-45 psychiatric mental health professionals in the Thereafter, the country experienced nurses. However, since the original Netherlands, South Africa, Gam- turbulent periods of occupation, civil training programmes ended, there has bia, Russia, China, Sri Lanka, and war, and the devastating regime of the been no regular training of psychiatric Myanmar. Through the Transcultural Khmer Rouge led by Pol Pot. During nurses.[2] Regarding medical specialists, Psychosocial Organization (TPO this regime (1975-1979), over two mil- the Cambodian University of Health Cambodia), he became affiliated lion people were killed or died due to Sciences took over the three-year psy- with the Khmer-Soviet Friendship starvation and disease. The subsequent chiatry residency training programme. Hospital (KSFH) in Phnom Penh, years brought misery until the Paris Cambodia, since 2015. HealthNet Peace Agreements of 1991, which ended PRESENT STATUS OF ­MENTAL TPO is a global aid agency with the Cambodian-Vietnamese war. HEALTH CARE roots and its headquarters in the Currently, Cambodia has about 16 Netherlands, which has been work- MENTAL HEALTH CARE WORK- million inhabitants. The present status ing on restoring and strengthen- FORCE AFTER THE PARIS PEACE of mental health care in Cambodia is ing health care systems in areas AGREEMENTS (1991) reflected in the total number of mental disrupted by war or disaster since At that time, the public health system health specialists. Cambodia has about 1992. The organisation is the result of Cambodia was demolished, and only sixty psychiatrists,[3] which is fifty times of a merger (in 2005) of the former a few medical doctors and other health less (calculated per 100,000 inhabit- TPO International and HealthNet. workers were still active. Quoting Daniel ants) than the Netherlands. TPO Cambodia was established in Savin: ‘In 1979, none of 43 surviving In addition, there are currently 1995 as a branch of the former medical doctors in Cambodia were about 200 psychologists working in TPO International and registered in psychiatrists.’[1] Many higher educated Cambodia as compared to 16,000 in Cambodia as a not-for-profit NGO people were killed in the name of the the Netherlands.[4] There are also only a in 2010. revolution of the Pol Pot regime. few government mental health clinics operating, predominantly located in urban centres. Finally, the total num- ber of psychiatric in-patient beds is below twenty. Since 2010, there have been strategic plans to improve mental health care in the country, particularly to increase the number of specialised clinics and enhance resources. However, in 2016, it was clear that the system was still ill-equipped and provided only limited services. Funding remained too low, resources too limited, and training initiatives and projects frequently relied on external funding.[5,6] Information on the training of psychiatrists and psychologists is presented in Table 1.

TPO CAMBODIA AND OUR VISITS TPO International engaged in the promotion of mental health in war and conflict zones worldwide, and started CAMBODIA AND ITS HISTORY Immediately after the peace agree- a community based mental health Nowadays Cambodia is one of the ments, the Cambodian government programme in Cambodia in 1995, with poorest countries in South-East Asia. formed international partnerships the aim of identification, prevention and However, it is a country with a glori- with the International Organization management of psychosocial problems. ous history between the 9th and the 14th for Migration (IOM) and the University

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PSYCHIATRIC TRAINING PSYCHOLOGIST TRAINING

6 yrs Medical + 3 yrs specialisation 4 years bachelor + 2 yrs master at University of Health Sciences at Royal University of Phnom Penh

Full time training Training only in the weekend No salary (need for wealthy parents) Work for their living during the week

Mainly biological framework and treat- Different psychological frameworks used ments

Work in state hospitals (600 USD Work in Private practices + counseling hospitals monthly) + private pactice

Table 1. Summary of training of psychiatrists and psychologists in Cambodia.

In the beginning, a core group was psychosocial and medical problems. In formed by Willem van de Put and other words, it is not common practice Maurice Eisenbruch,[7] which consisted to link the dynamics of the psychoso- of Cambodians who were offered cultur- cial system and the dynamics of the ally appropriate and relevant training, interpersonal communication with the monitoring and supervision - based stress put on the patient and the mental on the daily experience of assessing decompensation. Therefore, a broader Training on use of ECT apparatus existing problems and identifying understanding should be developed realistic solutions in the field of psy- of the pathogenesis of the psychiatric our conversations, we obtained chosocial problems in the community. disorder in a specific patient. We also insight into the great constraints of For example, in rural villages patients missed the contribution of patient mental health care in these areas. with psychotic disorders were of most organisations in the psychoeducation concern and therefore the staff of local and sharing of common problems of EXPERIENCE-DRIVEN hospitals were trained in basic mental patients. There seems to be little coher- ­RECOMMENDATIONS TO ADAPT health care to cope with these patients. ence in visions and working models of MENTAL HEALTH IN CAMBODIA Since 2000, the project has continued psychosocial workers, psychologists and Based on the experiences of the first its activities as the independent TPO psychiatrists. This appeared especially two authors (JvH, SR) with co-workers Cambodia.[8] Nowadays, TPO Cambodia relevant in the treatment of therapy- and also the conversations with leading is a relatively large Cambodian NGO, resistant patients. Therefore, in the people in the government, hospitals which plays a trendsetting and edu- programme, we performed a multilevel and NGO’s, we made the following cational role in mental health care problem analysis, with a biopsychoso- recommendations for improvement in developments. They realise outpatient cial model for better understanding the mental health care in Cambodia, which and social psychiatric care, particularly problems that the patients and their we will incorporate in the develop- in rural areas, and broadly provide infor- families are confronted with. On the ment of our future programmes. mation in the field of mental health. basis of this analysis, therapeutic inter- • Promote multidisciplinary coop- ventions were proposed. In addition to eration, e.g. in the KSFH also The first author (JvH) has participated system interventions, psychotherapeutic psychologists and social workers in TPO Cambodia’s capacity build- and pharmacological treatments of these could do a lot of good work, while ing programme since 2015, both in patients were discussed. In Phnom they are absent now. Furthermore, the capital Phnom Penh as well as Penh, many thousands of people are experts from ministries, hospital in rural areas. The capacity build- treated with antidepressants, but many managements, and assurance ing programme consists of lecturing, of them are treatment resistant and companies, practitioners, and tra- training small groups of psychiatrists, require other therapy. For these patients, ditional healers could focus more residents, psychologists and students we introduced electroconvulsive therapy on joint attention and cooperation. on main psychiatric diseases, diagnos- as a potential treatment, discussed • Psychotherapy could be used also tic procedures through roleplaying, its indication assessment, and also in a much more integrated man- and communication with patients. performed training on its application. ner. In this respect, it would be advisable to integrate the education The multi-disciplinary programme Finally, in the rural areas we provided of psychologists and psychiatrists operation and evaluation provided the training to various TPO Cambodia in order to improve cooperation. following insights concerning mental teams of mental health workers and • Psychiatry could benefit from health care practice. Patient problems employees of local hospitals, in par- more frequent use of second in various areas of life are evaluated and ticular on how to conduct a psychiatric generation psychotropics, like treated individually, without consider- interview and topics like depression, lithium and clozapine, especially ing the mutual relationships between schizophrenia, and addiction. Through for treatment of therapy-resistant

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patients. However, in that case, laboratory facilities have to be Jacques van Hoof, MD PhD improved to enable measurement Neuropsychiatrist NP, Radboud University of lithium plasma levels, mea- Nijmegen and private practice, surement of thrombocytes and the Netherlands further blood picture, and mea- [email protected] surement of drug plasma levels. • Patient organisations could be Sy Rato, MD initiated or strengthened, e.g. Psychiatrist, private practice Phnom Penh, Alcoholics Anonymous could Cambodia be invited to settle in the cit- [email protected] ies as well as in rural areas. • The highly motivated new genera- Cor Sennef, PhD tion of psychiatrists and psycholo- Psychologist, formerly Radboud University gists should be facilitated in Nijmegen, the Netherlands CAMBODIA further extending their knowledge, [email protected] e.g. by attendance of conferences HAS ABOUT or summer schools (also abroad). SIXTY • Under the guidance of governmen- REFERENCES PSYCHIATRISTS, tal institutions and local NGOs, 1. Savin D. Developing psychiatric training and services in Cambodia. Psychiatr Serv. 2000 consultation and education by Jul;51(7):935. DOI: 10.1176/appi.ps.51.7.935 WHICH IS FIFTY mental health care professionals 2. Olofsson S, San Sebastian M, Jegannathan B. Mental health in primary health care in a rural district of TIMES LESS from abroad could make a dif- Cambodia: a situational analysis. Int J Ment Health Syst. 2018 Jan 24;12:7. DOI: 10.1186/s13033-018-0185-3 ference. The recent initiative of 3. World Health Organization [Internet]. Mental Health (CALCULATED the department of transcultural ATLAS 2017 Member State Profile. 2017 [cited 2020 Nov 2]. Available from: https://www.who.int/mental_ PER 100,000 psychiatry of the Netherlands health/evidence/atlas/profiles-2017/KHM.pdf?ua=1. 4. Capaciteitsorgaan. Capaciteitsplan 2020-2024: Psychiatry Association to establish Beroepen Geestelijke Gezondheid: Deelrapport INHABITANTS) a group of psychiatrists interested 7 [Internet]. Utrecht, 2018 [cited Nov 2 2020] 109 p. Available from: https://capaciteitsorgaan. THAN THE in global mental health could also nl/app/uploads/2018/11/2018-11_02-DEF- Capaciteitsplan-BGGG-2020-2024.pdf support projects in Cambodia with 5. Parry SJ, Wilkinson E. Mental health services NETHERLANDS required expertise and means. in Cambodia: an overview. BJPsych Int. 2020 May;17(2):29-31. DOI: 10.1192/bji.2019.24 6. Jegannathan B, Kullgren G, Deva P. Mental health services in Cambodia, challenges and opportunities These recommendations were posi- in a post-conflict setting. Asian J Psychiatr. 2015 THERE ARE tively received by TPO Cambodia and Feb;13:75-80. DOI: 10.1016/j.ajp.2014.12.006 7. Somasundaram DJ, Van de Put WA, Eisenbruch ABOUT 200 the colleagues at KSFH. In addition to M, et al. Starting mental health services in Cambodia. Soc Sci Med. 1999 Apr;48:1029- internal Cambodian considerations, 46. DOI: 10.1016/s0277-9536(98)00415-8 PSYCHOLOGISTS these ideas convinced AROM, the 8. TPO Cambodia [Internet]. About us; [cited 2020 Nov 2]. Available from: https://tpocambodia.org/tpo-about/ recently initiated platform of psychia- WORKING IN trists and psychologists, to prioritise the CAMBODIA AS cooperation between both disciplines. COMPARED TO ACKNOWLEDGEMENTS 16,000 IN THE We thank the employees of the Louvain Cooperation Cambodia, especially NETHERLANDS Amaury Peters and Khem Thann, of TPO Cambodia, of The RUPP and KSFH, who supported JvH’s visit to Cambodia and were prepared to share their thinking with him. JvH also thanks all residents and stu- dents who made his teaching ses- sions an enriching experience.

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Art aimed at understanding the mentally ill

The fear of going crazy or losing part of Brooklyn, New York City. The oneself completely is one of the hospital is in a crowded neighbourhood greatest fears we know. One in four with mostly poor people with various people will face mental difficulties ethnical backgrounds experiencing in their lifetime. If it is not you, it is difficulties in surviving in the city. one of your friends, family members This is in striking contrast to Fukuroda or colleagues who suffers from a Hospital, about 160 kilometres from period of mental illness. Tokyo. In Japan, having a mental Unfortunately, this does not lead to illness is hard and especially shame- the understanding, solidarity and ful. As a result, patients are not seen financial support we have come in public. The town Daigo is a small, to know for other diseases such as aging city where most of the young cancer or aids. Psychiatric patients people have left. As Fukuroda Hospital are often stigmatised and the field provides patients with education and of psychiatry often suffers from teaches them skills, patients often financial limitations. As a result, continue living in the town. As a result, patients refrain from seeking treat- the town is becoming economically ment, or treatment is not acces- dependent on a marginalised group. sible at all. Poor access to mental Photo by Annaleen Louwes, from series: Black and and physical health care causes a white and (some) kind of blue or I only want to be All residencies share the following reduced life expectancy, exclusion happy themes. According to a systematic from higher education and employ- review by Leamy et al., the deter- ment, increased risk of contact with hospital and later in various Beautiful minants for personal recovery are: the criminal justice system, victimi- Distress activities. Art can tell the connectedness, hope and optimism sation, poverty and homelessness.[1] stories of psychiatry to a large audi- about the future, identity, mean- According to stigma expert Graham ence, which does not come in contact ing in life, and empowerment.[3] Thornicroft, the most widely used with mental illness or psychiatry on a and effective intervention to target daily basis. In contrast to earlier initia- As an example, the first residency at stigmatisation in psychiatry is to tives such as Het Vijfde Seizoen (The Kings County Hospital focused on the improve social contact between Fifth Season), the residencies were not first theme, connectedness. Annaleen mentally healthy and ill people. focused on the artistic development of Louwes was the first photographer the artist but on the implications their and white female in a mixed group of THE BEAUTIFUL DISTRESS FOUNDATION work has for the patient and society. patients. It took some time for her to In 2014, the Beautiful Distress foun- To promote social interaction around gain the trust of the patients. The gap dation was started with a mission to their work, all works are exhibited in between her and the patients became reduce psychiatric stigma through art closing meetings and symposia where smaller when she decided to reverse projects. Even though mental illness a broad audience is invited, includ- her photos in a negative colour scheme. often evokes negative emotions, it is ing policymakers, patients and their The result showed that all persons also a source of creativity. By bringing families, artists, health care practi- had the same blue-toned skin colour. these two worlds together, Beautiful tioners, and the general public. From that moment on, everybody Distress wishes to validate the world wanted to be in the project, which and experiences of the mentally ill.[2] THE RESIDENCIES resulted in an exhibition and a book Over the past years, various Dutch titled: Black and white and (some) kind Beautiful Distress organises residencies and international artists have entered of blue or I only want to be happy.[5] in different countries. The concept of the residency programme at Kings the residency is simple: the cooperating County Hospital in New York City and SOCIAL INTERACTION hospital provides an apartment and a Fukuroda Hospital in Daigo, Japan. Following a residency, the artworks studio within the hospital for a period The cultural differences and different are exhibited in the Beautiful Distress of three months. The resident artist perceptions of psychological vulner- House in Amsterdam or elsewhere. comes into contact with the patients and abilities are the start of an international Posters are hung throughout the city staff on various wards to do research exchange of images, ideas and solutions. to reach a broad audience. In addition, and practice their art. At the end of the a series of meetings called ‘mad- residency, the artist has produced a body Kings County Hospital is a huge public ness meets art’ is held where a broad of work, which is first shown in the mental health hospital situated in a poor audience including policymakers

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and the mental health institutes are FUTURE OUTLOOK present. Our aim is to present smart Beautiful Distress is an international Wilco Tuinebreijer and clear recommendations in order growing foundation with a mission to Psychiatrist, Mentrum, Arkin, and director to reduce stigma in psychiatry. fight psychiatric stigma through art of the Beautiful Distress foundation, the projects. Although current residencies Netherlands As a framework we use the publica- are on hold because of the Covid-19 [email protected] tion of Laemy et al. For example, Jan pandemic, exhibitions and meetings Hoek created a project Mental super- are still planned. For 2021, an exhibi- Ryanne Betgem powers in New York City.[6] He asked tion and education programme will Medical doctor, Mentrum, Arkin, the people to visualise their demons and start on the theme Psychiatry, sexuality Netherlands delusions with a twist: turn your and power. Not only Dutch artists, but demon into a creature which gives you also artists from Syria, Egypt, Armenia power. Together with the patients, he and Chile will reflect together on this REFERENCES searched for props and took pictures. theme. The foundation keeps grow- 1. Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce Vulnerability turned into strength. ing within the Netherlands and also mental-health-related stigma and discrimination. Identity and empowerment are the abroad. Especially in countries where Lancet. 2016 Mar 12;387(10023):1123-32 DOI: 10.1016/S0140-6736(15)00298-6 major themes. We repeated this in a access to mental health care is limited, 2. Beautiful Distress [Internet]. Waarom. Available from: www.beautifuldistress.org/overons-2-1 mental hospital in Amsterdam and storytelling through art, literature, 3. Leamy M, Bird V, Le Boutillier C, et al. are now in the process of collecting music or theatre can be an accessible Conceptual framework for personal recovery in mental health: systematic review and narrative the experiences. We will hold dis- way to reduce stigmatisation and clear synthesis. Br J Psychiatry. 2011 Dec;199(6):445- 52. DOI: 10.1192/bjp.bp.110.083733 cussions with our partners on how the path to better mental health. 4. Annaleen Louwens [Internet]. Available to convert those experiences into from: www.annaleenlouwes.nl 5. Jan Hoek [Internet]. Mental Superpowers. Available recommendations that will really from: https://janhoek.net/MENTAL-SUPERPOWERS combat prejudices against people with psychological vulnerabilities.

Photo by Jan Hoek, from: Mental superpowers, Exhibition Mentrum Amsterdam 2018

16 MT BULLETIN OF NVTG 2020 DECEMBER 04 CONSULT ONLINE

Anxiety disorder in Accra, Ghana

Usually you see a Consult Online services such as assessments, evaluation of her children. After initial assessment case report in MTb. This time we and diagnosing of patients with psycho- and monitoring, she was referred to the had wanted to present a case report logical disorders, provision of appropri- clinical psychologist for further manage- that relates to the theme of this ate therapeutic interventions, reviewing ment as all test results were negative. edition, but unfortunately we did them after psychological intervention, or A mental state examination (MSE) not have any at present. We take referring patients whose conditions call indicated a patient who appeared dull this opportunity to request you to for further management and specialised and lethargic, well orientated to place, in submit mental health questions care to other specialist professionals. person and time. In addition, the patient to our enthusiastic Consult Online In addition, the Clinical Psychology had poor insight into her hypertensive panel as well. For now we present Centre provides education on psycho- diagnosis. Her thought process was you a case from Ghana, written by logical and mental health topics such consistent and logical, but her thought Mohammed Salim Sulley Wangabi, as stress, anxiety and depression. content was fear of incapacitation from a clinical psychologist, who presents a stroke, which started over a month ago his insights in the mental health when she was put on anti-hypertensive care sector in West Africa. medication. The patient was initially accommodating but seemed sad. She SETTING started losing interest in the course of This case was seen in a modern the session, as she seemed in pain or regional hospital in Accra, the capi- discomfort, and was unwilling to tal of Ghana, with 620 bed capacity say what was wrong or how she and a variety of specialties includ- was feeling at that moment. ing a modest but expanding clini- She reported sleeplessness, cal psychology department. poor appetite, and palpita- tions that commenced BACKGROUND three weeks previously. The In Ghana, the estimated prevalence of patient is a mother of two mental disorders is 13% of the adult and living with her children population.[1] These disorders present in at a rented apartment. She a variety of forms and require various reported spiritual reasons that forms of care which could be either were stifling her business as well pharmacological or non-pharmacologi- as causing her medical conditions. cal. The mental health sector in Ghana She has a secondary education, and ses- depends to a large extent on pharma- sions were done in English with peri- cological methods of managing mental odic switches to Ga, her local dialect. illness due to widespread shortages of qualified personnel and resources for CASE BACKGROUND ASSESSMENT AND DIAGNOSIS psychosocial therapies and rehabilita- A 44-year old female business owner After initial consultation, a provisional tion. There is also the issue of stigmati- came to the emergency ward with a diagnosis of anxiety was made. The sation and superstition which is being sudden onset of breathlessness. She patient was taken through some basic grappled with. Mental disorders are had a medical history of hypertension, relaxation techniques to provide some prevalent but various factors, including for which amlodipine was started one form of relief. Furthermore, she was financial capacity and lack of insight, month previously. Now the patient com- assessed using the Hospital Anxiety have prevented the urgent management plains about breathlessness at rest dur- and Depression Scale (HADS). Her of depression and anxiety, amongst oth- ing the day, which worsens at night. She scores were high on anxiety and low ers, until they become severe, requiring presented with feelings of numbness, on depression, indicating a significant pharmacological interventions. The cold at the extremities and hot flashes. anxious thought pattern, feeling and Greater Accra Regional Hospital (Ridge) Additionally, she reported some physi- behaviour. The patient was diagnosed offers many health care services that ological discomforts such as headaches with anxiety disorder and psychothera- promote the health and general well- and uneasiness as well as inability to peutic interventions were started. being of Ghanaians. Notable among sit or lie down comfortably. The patient these services are the mental health expressed worries that she might be TREATMENT services. The Clinical Psychology Centre experiencing symptoms of stroke, which The patient was taken through the fol- is a professional and client-oriented made her scared as a stroke situation lowing therapies: progressive muscle department of the hospital that offers could render her incapable of taking care relaxation to reduce uneasiness and

DECEMBER 04 2020 MT BULLETIN OF NVTG 17 CONSULT ONLINE

facilitate sleep; cognitive restructuring CONCLUSION to replace maladaptive thought pat- The Clinical Psychology Centre still Mohammed Salim Sulley Wangabi terns precipitating her anxious feelings; faces teething problems but, as in this Clinical psychologist, Greater Accra insight therapy to provide understand- case, can provide significant psycho- Regional Hospital, Ghana ing of her conditions and the associated logical help for a wide range of people [email protected] symptoms, and coping techniques to with diverse mental health challenges. manage her behavioural changes due The centre also provides training and Daily Krijnen, MD to her current diagnosis. A week after supervision for both local and inter- Infectious Disease Control, Municipal the initial intervention the patient national students to prepare them in Health Services Zuid Limburg, the returned to explore its effectiveness. caring for people with mental health Netherlands She seemed to be more relaxed and less disorders. All these activities aim to [email protected] worried about her situation. Finally, she ensure a mentally healthy society with went through six sessions of cogni- insight and self-awareness. As this case Maud Ariaans, MD tive behaviour therapy and reported an demonstrates, awareness and attention Global Health and International Medicine in improvement in her thought patterns to mental health problems, resulting training, Gelre Ziekenhuizen Apeldoorn, the and emotions, and was feeling hopeful in a proper diagnosis and adequate Netherlands to proceed with her life activities. A post- treatment, can significantly improve [email protected] therapy HADS assessment indicated the health of members of society. an insignificant level of anxiety and depression as reported by the patient. REFERENCES

1. Oppong S, Kretchy IA, Imbeah EP, et al. Managing mental illness in Ghana: the state of commonly prescribed psychotropic Medicines. Int J Ment Health Syst. 2016 Apr 5;10:28. DOI: 10.1186/s13033-016-0061-y

Continuation of the article on Mental health and psychosocial support by Tessa Ubels (on p10-11) integration-of-mental-health-and-psychosocial-support- in-humanitarian-response/why-is-it-important-to- BACKGROUND INFORMATION­ a number of search terms (see table). integrate-mhpss-into-humanitarian-response The literature search was conducted 5. Wessells MG. Do no harm: Toward contextually appropriate psychosocial support in international by Vy Trân Nhât between 1 July 2020 Studies which did not describe unin- emergencies. Am Psychol. 2009 Nov;64(8):842- 54. DOI: 10.1037/0003-066X.64.8.842 and 20 September 2020. The seven tended effects and did not have any rele- 6. Shah SA. Ethical standards for transnational systematic reviews of MHPSS interven- vant keyword hits were excluded, leaving mental health and psychosocial support (MHPSS): do no harm, preventing cross-cultural errors and tions which were searched, are recently 23 studies. After reading the remaining inviting pushback. Clinical Social Work Journal. 2012;40(4):438-49. DOi: 10.1007/s10615-011-0348-z. published, between 2011 and 2019, articles in detail, the studies which only 7. Miller KE, Rasmussen A. War exposure, daily stressors, and focus on studies in man-made reported a lack of intended effects were and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and and natural humanitarian emergency excluded. In the end, twelve studies psychosocial frameworks. Soc Sci Med. 2010;70(1):7- 16. DOi: 10.1016/j.socscimed.2009.09.029 settings. To filter the studies in the were found to report unintended effects. 8. Summerfield D. A critique of seven assumptions seven reference lists, the following The seven systematic reviews and twelve behind psychological trauma programmes in war- affected areas. Soc Sci Med. 1999 May;48(10):1449- eligibility criteria were used: studies included studies are available at request. 62. DOI: 10.1016/S0277-9536(98)00450-X 9. Inter-Agency Standing Committee. IASC published after and including 1980, Guidelines on Mental Health and Psychosocial studies published in English, both Support in Emergency Settings [Internet]. Geneva: IASC; 2007 [date unknown; cited 2020 Oct 10]. quantitative and qualitative studies, both REFERENCES 205 p. Available from: https://www.who.int/ mental_health/emergencies/9781424334445/en/ man-made and natural humanitarian 1. Ministry of Foreign Affairs. Declaration: mind the 10. Koch D-J, Schulpen L. Introduction to the emergency settings, all types of MHPSS mind now [Internet]. Amsterdam: Government of the special issue ‘unintended effects of international Netherlands; 2019 [updated 2019 Oct 8; cited 2020 cooperation’. Eval Program Plann. 2018 Jun;68:202- interventions, interventions target- Oct 9]. 5 p. Available from: https://www.government. 9. DOI: 10.1016/j.evalprogplan.2017.10.006. nl/documents/diplomatic-statements/2019/10/08/ 11. Bamberger M, Tarsilla M, Hesse-Biber S. Why so many ing both adults and/or children and amsterdam-conference-declaration “rigorous” evaluations fail to identify unintended young people (CYP). 137 studies from 2. Ventevogel P, Van Ommeren M, Schilperoord M, et consequences of development programs: how mixed al. Improving mental health care in humanitarian methods can contribute. Eval Program Plann. 2016 the reference lists were found eligible, emergencies. Bull World Health Organ. 2015 Oct Apr;55:155-62. DOI: 10.1016/j.evalprogplan.2016.01.001. 1;93(10):666-A. DOI: 10.2471/BLT.15.156919 12. Jabeen S. Do we really care about unintended however, two studies were different 3. Liese BH, Gribble RSF, Wickremsinhe MN. outcomes? An analysis of evaluation theory and samples presented in a separate third International funding for mental health: a review practice. Eval Program Plann. 2016 Apr;55:144- of the last decade. Int Health. 2019;11(5):361- 54. DOI: 10.1016/j.evalprogplan.2015.12.010. study, and one PhD dissertation was not 9. DOI: 10.1093/inthealth/ihz040 13. Blanchet K, Ramesh A, Frison S, Warren 4. Government of the Netherlands [Internet]. Why is E, Hossain M, Smith J, et al. Evidence on accessible. 134 studies were therefore it important to integrate MHPSS into humanitarian public health interventions in humanitarian ultimately included. Titles, abstracts response? [Internet]. Government of the Netherlands; crises. The Lancet. 2017;390(10109):2287- 2019 [date unknown; cited 2020 Oct 9]. Available 96. doi:10.1016/S0140-6736(16)30768-1. and texts were scanned on the basis of from: https://www.government.nl/topics/mhpss/

18 MT BULLETIN OF NVTG 2020 DECEMBER 04 BOOK REVIEW

Een goede geest bestaat niet

By Amy Besamusca-Ekelschot in larger groups, but he makes sure to received funding to help Rwanda use Uitgeverij Mik Schots leave out the horrific details. When he their Westernised explanation model ISBN: 978-90-822310-1-4 is by himself, he often thinks back to for trauma, leaving out cultural aspects NUR: 301 what happened in such as the impor- 2018, 274 pages Rwanda and feels tance of keeping Language: Dutch guilty towards good relationships Price: 20 euros, to support the work those who didn’t with the spirits. of the NGO Kennis zonder Grenzen survive such as (Knowledge without Borders), his own mother. I would strongly www.kenniszondergrenzen.nl recommend reading One of the most this book because hen I asked my col- interesting aspects I think this story leagues in the mental of the story is should be heard. health sector what that despite all Most of the people I they knew about the the trauma he gave the book to so RwandanW genocide, the movie Hotel endured, Victor far found it hard to Rwanda came up most. This movie is is not suffering get through the parts based on the true story of a - accord- from typical post- where the traumatic ing to the movie - brave hotel manager traumatic stress experiences are of Hôtel des Mille Collines in Kigali, disorder (PTSD), described because of who was able to protect around 1,200 which has a the gruesome details, Tutsis from being slaughtered. The particular pattern but also found it movie ends with the reunion of the of symptoms such important that this main characters in a safe place outside as flashbacks, side of the genocide Rwanda, and it seems they are likely avoidance of trauma related triggers, is highlighted. For doctors working to live happily ever after. The book nightmares, and hyperarousal. Victor with psychiatric patients, it’s hard to Een goede geest bestaat niet (A good feels he doesn’t have the right to feel bad picture what the people of Rwanda spirit does not exist) shows a differ- about what happened, because he was have been through because it’s so ent side of the Rwandan genocide. one of the lucky ones. He got the chance different from reality as we know it. to start a new life, so he suppresses most The book follows the true story of Victor, of his feelings and does not seek any What this book mostly demonstrates is an ordinary young man with a Hutu professional help to process his memo- the various ways psychiatric symptoms father and a Tutsi mother. At the start ries. He sends money back to family can manifest themselves in people of the war, he is not considered Hutu members who remained behind, which with a different cultural background and has to flee on foot to neighbour- leads to confrontations with his wife. from our own. Doctors working with ing Democratic Republic of the Congo He frequently fears he may be hunted psychiatric patients are trained to (DRC). During the escape he witnesses by the bad spirits of his ancestors and diagnose and treat purely on PTSD horrible murders and deaths due to family and friends who didn’t make it. as described in the Diagnostic and disease, hunger, thirst and fatigue. Statistical Manual of mental disorders, No matter how hard he tries, he can’t Having lived in Belgium for over fifteen fifth edition, DSM-5. It would therefore avoid the smell of the dead bodies. His years, Victor returns to Rwanda to be of great value to pay more attention situation is bleak: he could be killed, work as a psychiatric nurse for a year. to the cultural expression of psychiat- he sees no future for himself, and he Being there physically, his memories ric symptoms in global mental health comes close to dying a number of times. intensify and he starts experiencing training and most of all, to remain nightmares and flashbacks. He keeps curious and ask open explorative ques- He manages to escape Rwanda, and this to himself, still feeling that others tions to each of our individual patients. from DRC he moves on to Belgium, suffered much more. He eventually where he suffers a brief period of finds some peace of mind by asking the depression. But he recovers without any spirits for forgiveness. At the end of the Afra van der Markt remaining severe psychiatric symp- book, Victor returns to Belgium. The Psychiatrist and researcher at GGZ inGeest, toms. He integrates well into Belgian importance of including cultural aspects Amsterdam, the Netherlands society, gets married, and becomes a is emphasised by several of his Belgian [email protected] psychiatric nurse. Frequently, he talks friends, with whom he discusses how about his past with friends and even non-governmental organisations that

DECEMBER 04 2020 MT BULLETIN OF NVTG 19 Membership of the Netherlands Society for Tropical Medicine and International Health (NVTG) runs from 1 January to 31 December and may commence at any time. Membership will be renewed automatically unless cancelled in writing before 1 December. Membership includes MTb and International Health Alerts. An optional subscription to TM&IH carries an additional cost. Non NVTG members can subscribe to MTb through a student MORE GLOBAL MENTAL membership of the Society for € 40 per HEALTH in the upcoming year by sending the registration form via NVTG symposium and webinar our website www.nvtg.org/lidworden or by sending name and postal address by e-mail to: [email protected] Please submit your contributions and announcements to the editorial office by e-mail: [email protected] Interested in learning more about, and Paul Bekkers, Special Envoy Mental discussing current issues in global Health and Psychosocial Support mental health? Please be invited to join of the Ministry of Foreign Affairs. Netherlands Society for Tropical the following ONLINE NVTG events: Medicine and International Health Marit Sijbrandij, Associate Professor president WEBINAR on Tuesday 19th of January Clinical Psychology, Vrije Universiteit J.A.E. (Joop) Raams from 19.30 to 21.45 (CET). This event Amsterdam and the World Health secretary is a follow-up to this edition of MTb Organization (WHO) Collaborating J.J. (Jaco) Verweij in which a number of the contribut- Center for Research and Dissemination secretariat ing authors will provide more detail of Psychological Interventions. J.M. (Janneke) Pala-Van Eechoud on their articles, and discuss topi- P.O. Box 43 8130 AA Wijhe | The cal issues in global mental health. Rembrant Aarts, psychiatrist at Netherlands | +31(0)6 156 154 73 | Mentrum Mental Health, MD Global [email protected] | www.nvtg.org SYMPOSIUM on Friday 22nd of Health and Tropical Medicine January from 14.00 to 17.00 (CET). (AIGT), will chair this session. COLOPHON ‘MIND MATTERS’, the annual NVTG MT Bulletin of the Netherlands Society symposium highlights current issues In the last hour of the symposium for Tropical Medicine and International Health in the field of global mental health, the Laureate of the firstSauerwein ISSN 0166-9303 with a special focus on mental health Medal will be awarded, we will and psychosocial support (MHPSS). launch the NVTG Knowledge Centre CHIEF EDITOR Global Health, and there is a ses- Leon Bijlmakers Keynote speakers include: sion organized by Uniting Streams Joop de Jong (psychiatrist, Em Prof of where young Global Health GUEST EDITORS Cultural Psychiatry and Global Mental researchers will pitch their work. Rembrant Aarts, Hans Rode (psychiatrists) Health, Amsterdam UMC; Boston University School of Medicine), Closing date for abstract sub- EDITORIAL BOARD mission: 9 AM January 15, Maud Ariaans, Remco van Egmond, Esther Jurgens, Olga Knaven, Daily Krijnen, Jake Mark Jordans (Professor of Child 2021, at: unitingstreams.org Mathewson, Gerine Nijman, Ed Zijlstra and Adolescent Global Mental Health,

University of Amsterdam; Director of Both events are online, free SECRETARIAT Research and Development at War of charge, in English and Olaf van Muijden Child Holland; Reader at the Center for ­accredited (NVTG, NVvP). Global Mental Health, King’s College LANGUAGE EDITING London) and his colleague Nagendra More information on: nvtg.org Eliezer Birnbaum Luitel (Head Research Transcultural Psychosocial Organization, Nepal; PhD Registration is required: COVER PHOTO Candidate University of Amsterdam). For the webinar: [email protected] Hanneke de Vries For the symposium: [email protected] DESIGN Mevrouw van Mulken 20 MT BULLETIN OF NVTG 2020 DECEMBER 04