Global Mental Health & Psychiatry Newsletter

Global Mental Health & Psychiatry NewsletterEliot Sorel, MD, Editor-in-Chief, CLM Founder

Zonal Editors Africa: Prof. David M. Ndetei, Kenya and Prof. Solomon Rataemane, South Africa

Asia/Pacific: Prof. Yueqin Huang, China and Prof. Roy Kallivayalil, India

Americas: Prof. Fernando Lolas, Chile and Prof. Vincenzo Di Nicola, Canada

Europe: Prof. Gabriel Ivbijaro, United Kingdom and Dr. Mariana Pinto da Costa, Portugal

Associate Editors Miguel Alampay, MD Rajeev Sharma, MD Veronica Slootsky, MD Mona Thapa, MD Milangel Concepcion-Zayas, MD Layan Zhang, MD

Eliot Sorel, MD Editor-in-Chief CLM Founder

Leadership, Innovation, and Early Career Development Eliot Sorel, MD

Newsletter Volume II, No. 3 September 2016

CLM/WPSCareer, Leadership

and Mentorship Program

Leadership, innovation, and early career development are the essential elements of our Newsletter’s current issue.

We are delighted to launch the new Early Career Reports from Around the World section in th is issue of the Global Mental Health and Psychiatry Newsletter. Contributions from Doctors Mariana Pinto Da Costa, Wasseem El Sarraj, Michael Morse, and Rajeev Sharma are only the beginning of what we hope will become an ongoing forum for leadership, innovation and stimulating early career development ideas, projects and global mental health initiatives.

We also appreciate the innovative and thought provoking contributions from Professors Luis Risco and Fernando Lolas of Chile regarding

the intrinsic link between Social Psychiatry and Ethical Medical knowledge, and the establishment of the Social Psychiatric Association of Chile; Professor David Ndetei thought provoking and inspiring rendition of the Africa Mental Health Foundation of Nairobi, Kenya; Professor Yueqin Huang’s sharing her country’s historic development of the Mental Health Survey, first of its kind in China; Professor Roy Kallivayalil’s sharing with us highlights of the rich scientific program of the XXII World Congress of the World Association for Social Psychiatry Congress in New Delhi, India, this December with the theme, “Social Psychiatry in a Rapidly Changing World”; and Professor Di Nicola’s inquisitive essay on “Where is the Family in Global Mental Health.”

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Volume II, No. 3 • September 2016

Table of Contents

CLM/WPSGMHP Newsletter

Career, Leadership and Mentorship Program

Career, Leadership and Mentorship (CLM) is a program of the

Washington Psychiatric Society.

Career, Leadership and Mentorship (CLM),a program for Residents

Members and Early Career Psychiatrists was founded by Eliot

Sorel, MD, with the generous support of the Washington Psychiatric Society, the Area 3 Council and the American

Psychiatric Association. It was started in 2008. CLM generates educational, research, leadership and mentoring

opportunities for our young colleagues to enhance the career development and leadership skills of the next generation

of health leaders.

Eliot Sorel, MD, Editor-in-Chief, CLM Founder

Social Psychiatry as an Expansion of Ethical Medical Knowledge. The constitution of a Chilean Association ........................ 3 Luis Risco, MD, President and Fernando Lolas, MDAFRICA ZONE: Africa Mental Health Foundation (AMHF) .......................................... 4 Professor David M. NdeteiASIA/PACIFIC ZONE: The China Mental Health Survey .......................................................... 6 Yueqin Huang, MD, MPH, PhD22nd Congress of Social Psychiatry ...................................................... 7 Professor Roy Kallivayalil and Rakesh K. Chaddathe AMERICAS ZONE: Where is the Family in Global Mental Health? ................................... 8 Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, FAPEUROPE ZONE: Early Career Psychiatrists Worldwide .................................................. 9 Mariana Pinto de Costa, MDEARLY CAREER REPORTS FROM ACROSS THE WORLD: Low Intensity Cognitive Behavioral Therapy .................................... 10 Dr. Wasseem El Sarraj and Michael Morse, MD, MPAPsychiatric Experiences ....................................................................... 11 Rajeev Sharma, MDSave the Date ......................................................................................... 12

GLOBAL MENTAL HEALTH & PSYCHIATRY NEWSLETTER of the Career, Leadership and Mentorship, Washington Psychiatric Society 3

Volume II, No. 3 • September 2016

Table of Contents

GMHP Newsletter

Social Psychiatry is field appropriate for raising and discussing social and interdisciplinary issues confronting current psychiatric research and practice. Among these, the increasing violence in our society and the world; religious, racial, gender and cultural differences expressed as intolerance; relation to the environment, natural and social; benefits and problems caused by the application of science and technology; the interfaces with other disciplines, within and without the healthcare field; the ethical responsibility of researchers and healthcare providers. Beyond the usual doctor-patient realm, issues arising in policymaking and epidemiological fieldwork are also a major concern for social psychiatrists, along with a reflection on the humanistic dimensions of medicine, psychiatry, and the neurosciences.Social psychiatry is the science of Anthropos, humankind. It is systemic and contextual in orientation and humanistic in tradition. (Sorel, 1998) It expands psychiatric thinking and practice beyond the limits of the clinical encounter and brings it closer to other disciplines dealing with human behavior, such as anthropology and sociology, without losing the “medical posture” that characterizes psychiatry in general. In times past, the so-called “medical model” was criticized because it represented what some would have called the “hegemonic” stance of the medical profession. It was argued that it did not address the complexities of the human condition in health and disease. It can be argued, however, that the correct understanding of the medical endeavor, from past immemorial, has always been integrative and holistic. What has sometimes been unilateral and restricted is theorization. In attempts at providing support for practices and interventions, physicians have resorted to other disciplines and have restricted their interests to biology, chemistry or social science. Medical practice has always been more than its alleged theoretical foundation, though in an implicit way. When it came to expand this foundation, the result has been juxtaposition of discourses with more apparent than real integration (Lolas, 2015).

SOCIAL PSYCHIATRY AS AN EXPANSION OF ETHICAL MEDICAL KNOWLEDGE. THE CONSTITUTION OF A CHILEAN ASSOCIATION

Social psychiatry, without losing ground in practice, emphasizes one dimension and provides an interface for a fruitful dialogue with other experts in the sciences concerned with human activity and products. It represents the best approach to a truly global mental health, considering cultural determinants and the necessary ethical grounding of a wide enterprise (Lolas, 2016)Along with efforts currently under way in many countries, it is expected that the creation of new associations, like the one now being established in Chile, will bring new momentum to the reflection on psychiatry as a discipline and medicine as an integrative practiceMembership in the Chilean Society for Social Psychiatry (CSSP) is available to all individuals certified or board eligible in psychiatry or currently in an accredited psychiatric residency training program and licensed to practice medicine in Chile. Exceptionally, certain non-psychiatrically trained physicians and allied mental health professionals may be proposed for Associate Membership status if proposed by a member in person or in a written letter to the board and subsequently voted into membership through a motion that is favorably acted on. Qualification for Associate Membership involves a demonstration of having made a significant contribution in promoting social factors in the field of mental health.Honorary Members will be appointed considering their contributions to world psychiatry or their commitment to the scientific foundations of the professionMembers are encouraged to advance their careers with a strong humanitarian imprint, devoting time to serve the interests of society.

Fernando Lolas, MD Luis Risco, MD

References:(1) Lolas, F. (2015) Fundamentos para una teoría de la medicina. Niram Art, Madrid (Foundations for a theory of medicine)(2) Lolas, F. (2016) Global mental health: challenges for a global ethics. Acta Bioethica 22(1):9-14. (3) Sorel, E., (1998)“Social Psychiatry: A mission and a vision for the 21st century”, Int’l Med J, Vol 5 No 4; 247-249

By Luis Risco, MD, President, Chilean Society of Neurology, Neurosurgery and Psychiatry, Associate Professor, University of Chile and Fernando Lolas, MD, Professor and Director, Interdisciplinary Center for Studies in Bioethics, University of Chile

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AFRICA MENTAL HEALTH FOUNDATION (AMHF)

by Professor David M. Ndetei

HISTORY Africa Mental Health Foundation (AMHF) is a non-governmental organizationfounded in 2000 by Prof David Ndetei. AMHF was formally registered in 2004 with a mandate to conduct rigorous mental health research and inform public

policy initiatives. AMHF is committed to innovative implementation research aimed at integrating mental health into primary care, improving access to treatment services, and incorporating evidence-based interventions into the routine care of mental illness. OUR PROJECTS Over the past 15 years, we have played a key role in advocating for better mental health initiatives, building capacity for mental health researchers and clinicians, and carrying out research to ensure the effective care and rehabilitation for individuals with mental illness. We have implemented over 20 projects throughout Kenya and built an extensive network of national, regional, and international collaborators and stakeholders.Some of our projects include: 1. The Kenya Integrated Intervention Model for Dialogue and Screening to Promote Children’s Mental Wellbeing - A multi-stakeholder model for primary schools that seeks to promote mental well-being, prevent mental illness and reduce the mental health treatment gap for children.2. Community Recovery Achieved Through Entrepreneurism - A proof of concept project using economic engagement and psychosocial rehabilitation modules to improve the recovery process of people with serious mental illness.3. The Computer-Based Drug and Alcohol Training Assessment in Kenya - A computer-based training project intended to build the capacity of primary healthcare workers to identify and treat substance use disorders.4. The Dialogue Project - A study utilizing traditional and faith healers to deliver evidence-based psychosocial interventions to patients seeking services.

5. Mobile Substance Use Intervention for HIV Prevention - A technologically-integrated project where clinicians use mobile phones to to treat substance abuse through motivational interviewing.6. Multisectoral Stakeholder TEAM Approach to Scale-Up Community Mental Health in Kenya - A project which partners with the local and national government to integrate mental health into the mainstream primary healthcare using existing community structures. SUCCESSFUL OUTCOMES Our projects have led to a reduction in mental health-related stigma in the community, an improvement in academic performance of school children, and an increase in help-seeking behavior among community members. Furthermore, we have witnessed community mobilization and willingness to actively support mental health programs. Our outcomes include the successful and fruitful facilitation of a dialogue between indigenous healers and formal health workers on the optimum ways to address mental health challenges in Kenya. Our greatest achievement is the strong partnerships we have formed with County, National and International bodies integrate mental health into the primary health care. The Makueni county government has shown great initiative by allocating a greater proportion of their budget towards mental health services in Kenya. AMHF is now scaling up its successful projects to other counties and countrywide.

PROFESSOR DAVID M. NDETEIWPA Zone 14 Representative Professor of Psychiatry University of Nairobi, Kenya Founding Director, Africa Mental Health FoundationEmail:[email protected]/[email protected]: www.africamentalhealthfoundation.org

References: (1) Ndetei, D., Mutiso, V., Musyimi, C., Mokaya, A., Anderson, K., McKenzie, K., & Musau, A. (2016). The prevalence of mental disorders among upper primary school children in Kenya. Social Psychiatry and Psychiatric Epidemiology, 2016; 51(1), 63–71(2) Ndetei DM., Mutiso V., Maraj A., Anderson KK., Musyimi C., Kwame M. Stigmatizing attitudes toward mental illness among primary School children in Kenya Soc Psychiatry Psychiatr Epidemiol 2015). DOI 10.1007/s00127-015-1090-6


AFRICA

Cape Town, South Africa

Africa Mental Health Foundation team, Nairobi Kenya.

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THE CHINA MENTAL HEALTH SURVEY

Mental disorders, as a community common disease with complex aetiology and increasingly prominent burden, have been paid more and more attention globally. Currently, with rapid economic development of China, psychosocial stress in different ways has increased. It probably results in higher prevalence and incidence of mental disorders, and increases instability of the society. In regard of mental health services, the contradictions between absolute lack of mental health resources for demand and low utilization of mental health services have become more and more prominent. The study on disease burden of mental disorders was paid little attention in the past because of limited research resource, which led to the lack of authoritative scientific data. Therefore, it is urgent to obtain the basic information of national disease burden of mental health by means of high-quality scientific research.Based on the recent 30-year experience of mental health survey in community population in China, China Mental Health Survey (CMHS) aims to conduct high-quality mental health survey in China. In this survey, the latest psychiatry theory and diagnostic criteria and epidemiological methods will be used. For the purpose of getting data with high validity and reliability, the experience from international investigation, quality control and organizational management approach will also be drew during the project. The prevalence rates and their distributions of depressive disorder, anxiety disorders, substance use disorders, schizophrenia, dementia and other types of mental disorders have been obtained, and various pathogenesis and risk factors for these mental disorders have been explored by observational and analytic epidemiological methods. In addition, an integrated system of screening and diagnosis of mental disorders, and a general system of

data collection and quality control of epidemiological research will be developed in Chinese population.CMHS has showed the prevalence, disease burden, psychosocial and environmental risk factors of mental disorders, and mental health service uses in China. National Health and Family Planning Commission of People’s Republic of China will release the report of CMHS on October 10, the World Mental Health Day. As a consequence, valid evidences will be provided for policy makers in mental health so as to allocate national health resources more scientifically, effectively and equitably. CMHS also can enhance Chinese academic position in the world, in terms of the researches of disease burden of mental disorders.

by Yueqin Huang, MD, MPH, PhDProfessor of Psychiatric EpidemiologyInstitute of Mental Health, Peking University

Yueqin Huang, MD, MPH, PhDProfessor of Psychiatric EpidemiologyVice-president, China Disabled Persons’ FederationDirector, Division of Social Psychiatry and Behavioural Medicine, Institute of Mental Health, Peking University, P. R. ChinaPresident, Chinese Mental Health JournalPresident, Society of Crisis Intervention of Chinese Association of Mental Health

References: (1) Liu Zhaorui, Huang Yueqin, Chen Xi, Cheng Hui, Luo Xiaomin. The prevalence of mood disorder, anxiety disorder and substance use disorder in community residents in Beijing : A cross-sectional study. China Mental Health Journal, 2013, 27(2): 102- 110(2) Yueqin Huang. Epidemiological Study of Mental Disorders in Mainland China. Taiwanese Journal of Psychiatry (Taipei), 2013, 27(2): 101-109 (3) Shen YC, Zhang MY, Huang YQ, He, Y-L., Zhao, Z-R., Cheng, H., Tsang, A., Lee, S., Kessler, R.C. Twelve Month Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in Metropolitan China, Psychological Medicine. 2006, 36(2): 257-268


ASIA/PACIFIC

The World Association of Social Psychiatry was founded in 1964 under the leadership of Joshua Bierer (UK) who was the founder President. The 1st World Congress was held in 1964 in London. This is third time, India is hosting the WASP Congress, having earlier hosted the 13th Congress at New Delhi in 1992 and the 17th Congress at Agra in 2001. This is heartening news! If the 19th century belonged to descriptive psychopathology, the 20th century to psychological and physical treatments, the 21st century is widely regarded to be belonging to Social Psychiatry. As we meet at New Delhi some of the themes upper most in our minds will be fighting against social exclusion, stigma, coercion and wide spread neglect of mental health in many parts of the world. XXII World Congress of Social Psychiatry is being held at New Delhi, India from 30th November-4th December 2016. The Congress is being organised by the Indian Association for Social Psychiatry. Professor Tom Craig, President, World Association of Social Psychiatry is the Congress President and Professor Roy Abraham Kallivayalil is the Chair, Scientific Committee. The theme of the Congress at New Delhi, “Social Psychiatry in a Rapidly Changing World” is contemporary and relevant. The Congress is being co-sponsored by the World Psychiatric Association and the Indian Psychiatric Society. The venue for the conference, Hotel the Ashok, symbolizes the traditional grandeur and hospitality of the historic capital of India. The scientific programme includes a theme symposium, 75 symposiums, 14 workshops, 12 plenary lectures, more than 100 free papers and about 300 poster presentations. The Congress will also have a young psychiatrist programme and a quiz for postgraduate residents. The confirmed speakers include Professors WASP President Tom Craig, President-Elect

22ND WORLD CONGRESS OF SOCIAL PSYCHIATRY NOVEMBER 30 - DECEMBER 4, 2016 NEW DELHI, INDIA

by Prof Roy Abraham KallivayalilChairman, Indian Medical Association National Committee for Mental Health

Rakesh K. ChaddaChair, Organizing Committee [email protected]

Roy Abraham Kallivayalil (India), Norman Sartorius (Switzerland), Laurance Kirmayer (Canada), Eliot Sorel (USA), Dinesh Bhugra (UK), José Miguel Caldas de Almeida (Portugal), Tsutomu Sakuta (Japan), Driss Moussaoui (Morrocco), Stephen Scott (UK), Helen Killaspy (UK), Helen Herrman (Australia), Vijoy Varma (India), R Srinvasa Murthy (India), Vikram Patel (India) and Mohan Issac (Australia).The Congress is likely to be attended by more than 1000 delegates from more than 35 countries. Delhi has a very pleasant weather during early December. It is a vibrant, affordable, colorful and friendly city with thousands of years of culture and history. The city is well connected by International and Domestic flights and boasts of a wide range of hotels, including 5 star and budget hotels to suit the requirement of each delegate. We have also arranged for a variety of pre and post congress tours for the delegates, who would like to visits the places of tourist attraction. The Taj Mahal, one of the 7 wonders of the world is just 2 hours journey from Delhi. Further details can be accessed at www.wasp2016.comHearty welcome!

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WHERE IS THE FAMILY IN GLOBAL MENTAL HEALTH? by Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, FAPA Chief of Child and Adolescent PsychiatryMontreal University Institute of Mental HealthProfessor of Psychiatry, University of Montreal

In a bold editorial, cultural psychiatrist Arthur Kleinman argued for a rebalancing of academic psychiatry, citing global mental health (GMH) as an emerging priority: “Global health is now squarely on the agenda of students, researchers and funders.” (Kleinman, 2012, p. 421). Community, psychosocial, and cultural aspects, as well as “social, moral and economic” factors are duly mentioned. Nowhere do the words family and relationship appear.I recently posed the question, “What is GMH?” (Di Nicola, 2016). A major volume in this emerging field of-fers this definition as a starting point:

Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people world-wide. Global mental health is the application of these principles to the domain of mental ill-health. (Patel, et al., 2014)

While we debate the best way to capture just what it is we want toaccomplish with GMH, I want to ask: Where is the family in GMH? Child and adolescent psychiatrists are already taking GMH seriously and taking stock of its import (see Joshi, et al., 2016). In Eliot Sorel’s volume, 21st Century Global Mental Health (2012), I examined the family, psychosocial, and cultural determinants of health (Di Nicola, 2012). These are critical and essential aspects that demand study and inclusion in any compre-hensive view of health. We cannot have a truly global movement for mental health without acknowledging the problems in our current models of health and illness that shape our models of health care delivery without includ-ing local health cultures and healing traditions.Those of us who work with mental health issues from a family perspective believe that seeing individuals in isolation is limited and ignores, minimizes or discounts the importance of relationships as both resources for health and as risk factors for illness. Furthermore, the work on attachment (which is theoretically important and clinically fertile) and belonging (its counterpart in social and cultural psychiatry addressing aspects of affiliation, identity, and social cohesion) demonstrates that relation-ships in general are avenues for treatment from both a family therapy perspective and the social determinants of health perspective (Di Nicola, 2012). This is the systems or relational approach to health. Relational means seeing

families as the bearers of the cultures they come from and their own unique cultures (Di Nicola, 1997, 2011).From a family perspective, GMH appears as a regressive step to the usual Western health categories that focus on individuals as bearers of larger issues in the family, community, society and culture. These larger envelopes are addressed in the impersonal way of categories—e.g., child abuse, substance abuse, violence, and treatment gaps—rather than from the relational, social and cultural perspectives that define mental health and illness more fully, meaningfully, and realistically. These aspects of GMH may deepen the practitioners’ perception of public health and epidemiology and their international organizations as being removed from clini-cal concerns and from their meaningful relational con-texts. Without such notions as attachment and belonging, ignoring the most significant of human relationships based on the family and community, GMH risks creat-ing another disembodied field divorced from our lived experience as communal and relational beings.

Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, FAPAProfessor of Psychiatry, University of MontrealRepresentative to the APA AssemblyPast-President of the Quebec & Eastern Canada District BranchNewsletter Zonal Co-Editor for the Americas

References: Di Nicola, Vincenzo. A Stranger in the Family: Culture, Families, and Therapy. New York & London: W.W. Norton, 1997. Di Nicola, Vincenzo. Letters to a Young Therapist: Relational Practices for the Coming Community. New York & Dresden: Atropos Press, 2011.Di Nicola, Vincenzo. Family, psychosocial, and cultural determinants of health. In: Sorel, Eliot, ed., 21st Century Global Mental Health. Burling-ton, MA: Jones & Bartlett Learning, 2012, pp. 119-150.Di Nicola, Vincenzo. Forum: Defining global mental health and psychiatry. Global Mental Health & Psychiatry Newsletter, January 2016, I (2): p. 11. Joshi, Paramjit T. and Lisa Cullins, eds. Global Mental Health Issue. Child and Adolescent Psychiatric Clinics of North America. January 2016.Kleinman, Arthur. Editorial: Rebalancing academic psychiatry: why it needs to happen – and soon. British Journal of Psychiatry Dec 2012, 201 (6): 421-422.Patel, Vikram, Harry Minas, Alex Cohen, Martin J. Prince, eds. Global Mental Health: Principles and Practice. Oxford, UK: Oxford University Press, 2014.Sorel, Eliot, ed., 21st Century Global Mental Health. Burlington, MA: Jones & Bartlett Learning, 2012.

the AMERICAS


EUROPE

The Section of Early Career Psychiatrists (ECPs) of the World Psychiatric Association (WPA) was created to encourage ECPs to network, learn, research and succeed in international collaborations.1

One of the great values of having such a section is to ensure the autonomy of ECPs within the WPA under the umbrella of guidance and warm advice of senior colleagues whenever needed. The section wishes to proceed with several collaborative activities with ECPs associations, aiming to enhance high standard training, and reflect the needs of ECPs in leadership, which can eventually improve mental health services worldwide, since usually ECPs are their backbones2.

Likewise, using web tools, ECPs can communicate closer with world-leading experts in psychiatry, without leaving their countries. These key features are just a milestone of a long list of possibilities that can be ultimately achieved together with its members. We warmly invite ECPs from all over the world to join the section, focusing their contributions in whichever areas they think are most necessary.

Hussien Elkholy (Egypt), Florian Riese (Switzerland), Felipe Picon (Brazil), Mariana Pinto da Costa (Portugal), Takashi Nakamae (Japan), Prashanth Puspanathan (Australia)

References:(1) Fiorillo A, Pinto da Costa M, Nakamae T, Puspanathan P, Riese F, Picon F, Elkholy H. Associations of early career psychiatrists worldwide: history, role, and future perspectives. Middle East Current Psychiatry (2016), 23:3–9.(2) Fiorillo A, Brambhatt P, Elkholy, H, Lattova Z, Picon F.Activities of the WPA Early Career Psychiatrists Council: the Action Plan is in progress. World Psychiatry, (2011) 10(2), 159.

EARLY CAREER PSYCHIATRISTS WORLDWIDEby Mariana Pinto de Costa, MD

Mariana Pinto da Costa International Coordinator of the BrainDrain study Psychiatry Trainee, Hospital de Magalhães Lemos, Porto, Portugal Contact: [email protected]

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Low Intensity CBT (LI CBT) is an umbrella term for a set of problem specific interventions1. Waseem El Sarraj, psychological wellbeing practitioner has trained in LI CBT within the United Kingdom National Health Service model known as ‘Improving Access to Psychological Therapies’ (IAPT). Having worked as a LICBT therapist he found that the UK general public were by in large very unfamiliar with this model of linking thoughts, feelings and behaviors. For example one of the LI CBT interventions known as Be-havioral Activation, is at its core about getting ‘deactivated’ patients to recognize how their low mood can negatively color their view of the world, themselves and the future, as well as decrease motivation, leading to a reduction in the pursuit of activities and goals that may bring pleasure2. Having found a high degree of patient satisfaction with this approach in the UK it seemed reasonable for the Palestin-ian Medical Education Initiative (PMED) to explore its salience to a Gaza population.In an effort to learn more about the usefulness of CBT and within a broader mandate of introducing mental health to primary care staff the PMED arranged a workshop with 15 primary care health workers (nurses, doctors and psycholo-gists) in the Gaza Strip. PMED had planned to visit Gaza in March 2016 but found obtaining permission to enter problematic. PMED was forced to conduct the training via Skype from Amman, Jordan. There were no technical dif-ficulties and the training was conducted without problem. There were three parts to the workshop: an introduction to the IAPT service model in the UK, the assessment and treatment of depression, and the assessment and treatment of generalized anxiety disorder. Participants were attentive and curious throughout the training and the trainer sought regular verbal feedback from the group, and was able to ascertain that the group had a solid understanding of CBT principles and where LI CBT interventions sit in the gambit of evidence based mental health interventions.At the end of the session the group was engaged in an hour-long discussion on the validity of LI CBT for a Gaza popula-tion. The first objection raised was how effective such simple interventions would be to a population experiencing chronic effects of occupation and war. The second objection was that

LOW INTENSITY COGNITIVE BEHAVIORAL THERAPY

by Dr. Wasseem El Sarraj, London, UK Psychological Well Being Practitioner National Health Service and Michael Morse MD, MPA

the community already has ways to cope such as religion, civic engagement and tight social bonds. However, it was noted that religion is a ‘double edged sword’ as it can lead some people to seek out religious healing which in many cases is ineffective for mental illness.Despite these objections the workshop group liked the sim-plicity of the CBT model and how insight into mood can be gleaned from linking thoughts, feelings and behaviors. Participants were in agreement that LI CBT would likely not be harmful. When asked about delivering the psycho-education participants agreed that social media would be a helpful way to reach large parts of the Gaza population.Overall, the workshop represents a first step to exploring the usefulness of LI CBT for a Gaza population. Further work will require the testing of interventions whilst ad-dressing the need to situate interventions within the context of war and occupation. As well as being mindful of the sources of resilience found not in the individual but in the community and wider society.Dr. Wasseem El Sarraj, London, UK Senior Director, Palestinian Medical Education Initiative Psychological Wellbeing Practitioner, National Health Service, England

Michael Morse MD,MPA Executive Director, Palestinian Medical Education InitiativeDirector, Program in Global Community Mental Health, Department of Psychiatry, George Washington University Dr. Morse is training in Child and Adolescent Psychiatry Fellowship- CNMC, Washington DC

The Palestinian Medical Education Initiative (PMED) is a nonprofit which supports the people of Palestine through international partner-ships in medical education and health service program development. www.pmedonline.org

References: (1) Roth, A. Pilling, S. 2008. Using an evidence based methodology to identify the competences required to deliver effective cognitive and behavioral therapy for depression and anxiety disorders. Behavioral and Cognitive Psychotherapy, 36, 129-147(2) Hopko, D., Lejuez, C., Ruggiaro, K. & Eifert, G. (2003). Contemporary behavioural activation treatments for depression: procedures, principles and progress. Clinical Psychology Review, 23, 699-717.l

Dr. Michael Morse Wasseem El Sarraj

E A R L Y C A R E E R R E P O R T S F R O M A C R O S S T H E W O R L D


I am an early career psychiatrist who has been fortunate to work in three different countries with different cultures and varying socio-economic backgrounds; these three are India, Singapore and USA. One major common personal factor was that in all the three countries I practiced in public setting hospitals. It can be argued whether manifestations and management of different common mental illnesses vary across nationalities or cultures. My earliest experience in psychiatry was in my home country in India as an Intern (fresh from medical school) and as a house officer. Psychiatric illness still has a lot of stigma in some societ-ies and in India it is simply huge but attempts are being made by various psychiatry societies and the government to alter this perception and consider mental illness as akin to any physical disease and seek proper therapy without being bound by baseless and ignorant concepts about psychiatric illnesses. Looking back, I see that talking to the patient in his language can be a big ad-vantage (compared to when I worked in Singapore). There were significant administrative and cultural differences in working styles and facilities available in all 3 countries which directly or indirectly definitely affected patient care. In India families are generally involved in patient care as families are very closely knit .The major obvious advantage of this is the patient most of the times receives good family sup-port and has strong a fallback system. A minor disadvantage from this positive family support system that I noticed was that patient autonomy in making decisions was sacrificed at times, although in my view the advantages of huge family support outweigh this tremendously. Another striking point I noticed was families would always add a spiritual or a religious angle to their loved one’s mental illness. Not uncommonly the families would seek help of spiritual or religious affiliates. The patient would also bring in their faith in dealing with the stress of their mental illness; prayers, spiritual teachers and at-times medita-tion. Psychiatry Consultations are often sought, especially by the rich, for minor issues often confusing the role of psychiatrist as a counselor rather than a physician. On television channels many psychiatrists are seen discussing psychological issues; the role of them as counselors remains ill defined. Recently substance abuse has also become a major problem in some states of India and addiction psychiatry is gaining great attention and scientific data support that prevalence of drug abuse and addiction has already become epidemic in certain states .My work as Medical Officer in a leading and largest public psy-chiatric hospital in Singapore was a great learning experience. Singapore has been voted as one of the most efficient models of socialized medicine in the world. The administrative govern-ing style in Singapore is meticulous and it is so also in medical services. In Singapore most patients speak in Chinese and I was at times utilizing help of a translator. I realized that the language barrier can causes difficulties in establishing a rapport but at the end of the day what matters is physician empathy, experi-

ence and knowledge. These help in establishing rapport and satisfaction of obtaining patient and patient's family's trust. The language barriers may cause its frustrations both to the patient and the physician but experienced psychiatrist has to take all this in stride and be able to provide the best services that he is capable of. Like India, Singapore also is fighting in dealing with stigma of mental illnesses. As noted earlier the very effective work ethics and high set standards in place in their culture has taken its toll as high stress related mental illnesses. Singapore has expanded psychiatric care to children which is also of very high quality. The spectrum of mental illnesses was also very similar to what I encountered in India but with varying prevalence and similarly cultural influences seemed to play a role also in dealing with stressors from mental illnesses. Substance abuse (especially illicit drugs) is not as prevalent in Singapore arguably due to very strict laws and punishments.In U.S. where I am working as a attending Psychiatrist after completing my residency from a state hospital and am currently working in the same institution. Here along with mental illnesses substance abuse is more prevalent as compared to Singapore. The socioeconomic factors are seen to play hugely in prevalence of mental illnesses. Forensic psychiatry is much more involved as compared to public state psychiatric settings in India. In the U.S. apart from medications, other treatment modalities are also used in public hospitals. The treatment strategies include various therapies-individual and groups, music, art and dance therapy. The current treatment goal in most state hospitals is to rehabili-tate the individual in care back to the community. Compared to India individuals from the lower socio comic status are provided with much better access to psychiatric care and more compre-hensive services. But the billing and insurance procedures in both private and public sector health care institutions are surely, perhaps unavoidably, much more complicated than India or Singapore.Finally realizing that though all 3 countries present with different cultures and human experiences but the biggest commonalty is that all human beings are the "same" at the end of the day. Each person as a patient has similar concerns of well -being, similar ambitions and similar problems-well-being remains the most vital. Languages and faces may differ and vary but the “depres-sion" remains depression and "pain" of the mental illnesses remains pain- easily seen and the same everywhere.

References:(1) Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the “Punjab model”) Indian J Psychiatry. 2015 Jan-Mar; 57(1): 9–20. doi: 10.4103/0019-5545.148509(2) World Health Organization Assesses the World’s Health Systems http://www.who.int/whr/2000/media_centre/press_release/en/

PSYCHIATRIC EXPERIENCES Rajeev Sharma, MD District of Columbia Department of Behavioral HealthWashington, DC

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