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Individuals’ mental health and wellbeing are dependent on many social factors including housing, employment, education and adequate nutrition among others. These factors can influence at personal, family and community levels. The interlinked and cumulative impact of these social determinants needs to be ascertained to aid appropriate patient management, as well as to establish prevention and health education programmes. Some of these determinants also have to be recognised at policy level. It is crucial for clinicians to understand the role social determinants play in the genesis and perpetuation of mental and physical illnesses, so that appropriate social interventions can be set in place. Clinicians have a role to play in their clinical practice, as well as advocates for their patients and policy leaders. In order to ensure that health is joined up with other sectors, such as education, employment, judiciary and housing, policy-makers must avoid silos. Every policy must have an impact assessment on physical health and mental health. Policy-makers need to understand scientific evidence and must work with researchers, clinicians, communities and patients to help develop and implement rights-based policies.
International medical graduates provide a valuable service to the healthcare of their adopted countries. However, there remain a significant number of challenges in their adjustment and acculturation in the post-migration phase. We believe that the cultural capital these doctors bring with them can act as a support as well as a challenge. They are likely to face subtle and not-so-subtle, covert and overt discrimination at a number of levels. In this brief report, we highlight some of the issues faced by them and some potential solutions.
How mental health affects males is a topic of increasing interest within psychiatric research. This stems not only from public health campaigns looking at male suicide rates but also campaigns on so-called cultures of ‘toxic masculinity’; a sociological concept suggested to be behind the creation of environments endorsing antisocial behaviour such as violence and sexual assault (see also Chapters 15 and 17). However, when first deciding to study epidemiology and modifying risk factors in the development of psychopathology in males, we must establish a way of measuring a socially constructed concept that varies hugely dependent on culture. In this chapter we explore the concept of gender identity and roles in society, its difference from biological sex, and how the concept of gender varies between cultures. By looking specifically at gender, we can then begin to investigate the stresses that can occur from psychosocial gender constructs and how these may contribute to male mental health problems and other risk behaviours. Of noticeable importance are the higher rates of psychiatric illness among male migrants along with other contributing factors such as sexual orientation in the development of mental illness. The clinical implications for identifying at-risk individuals and providing treatment in the area of male mental health, is discussed. A key aspect that must be remembered is that there are challenges in definition of gender and non-binary divisions (see also Chapter 8).
Homophobia is still a scourge in the modern era. Despite a greater acceptance of sexual variations and same-sex marriage in many countries, homophobia is widely sustained by religious, political and cultural values and beliefs at individual and social level. Most of homophobic attitudes are based on the principle of heteronormativity according to which heterosexuality is the standard for legitimating social and sexual relationships and homosexuality is considered as an abnormal variant. Homophobia may be also recognised at institutional level (state-sponsored homophobia, social homophobia) and supported by laws or religious beliefs. Moreover, internalised homophobia (IH) is defined as the inward direction of societal homophobic behaviours at individual level and refers to the subjective psychological impact of these negative attitudes. In fact, IH is significantly associated with a high prevalence of internalising mental disorders such as depression, anxiety, stress/trauma-related disorders, etc. We believe that a set of immediate actions are needed in order to contrast homophobia and its impact on mental health, in particular political initiatives, educational trainings and scientific research should be promoted with a specific focus on mental health needs of people target of homophobia.
The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.
Rapid urbanization worldwide is associated to an increase of population in the urban settings and this is leading to new emerging mental health issues. This narrative mini-review is based on a literature search conducted through PubMed and EMBASE. A total of 113 articles published on the issue of urban mental health have been selected, cited, reviewed, and summarized. There are emerging evidences about the association between urbanization and mental health issues. Urbanization affects mental health through social, economic, and environmental factors. It has been shown that common mental syndromes report higher prevalence in the cities. Social disparities, social insecurity, pollution, and the lack of contact with nature are some of recognized factors affecting urban mental health. Further reserach studies and specific guidelines should be encouraged to help policy makers and urban designers to improve mental health and mental health care facilities in the cities; additional strategies to prevent and reduce mental illness in the urban settings should be also adopted globally.
There is a lack of studies evaluating smoking cessation treatment protocols which include people with and without mental and substance use disorders (MSUD), and which allows for individuals with MSUD undergoing their psychiatric treatment.
We compared treatment success between participants with (n = 277) and without (n = 419) MSUD among patients in a 6-week treatment provided by a Brazilian Psychosocial Care Center (CAPS) from 2007 to 2013. Sociodemographic, medical and tobacco use characteristics were assessed at baseline. Tobacco treatment consisted of 1) group cognitive behavior therapy, which included people with and without MSUD in the same groups, and 2) pharmacotherapy, which could include either nicotine patches, nicotine gum, bupropion or nortriptyline. For participants with MSUD, tobacco treatment was integrated into their ongoing mental health treatment. The main outcome was 30-day point prevalence abstinence, measured at last day of treatment.
Abstinence rates did not differ significantly between participants with and without MSUD (31.1% and 34.4%, respectively). Variables that were significantly associated with treatment success included years smoking, the Heaviness of Smoking Index, and use of nicotine patch or bupropion.
The inclusion of individuals with and without MSUD in the same protocol, allowing for individuals with MSUD undergoing their psychiatric treatment, generates at least comparable success rates between the groups. Predictors of treatment success were similar to those found in the general population. Facilities that treat patients with MSUD should treat tobacco use in order to reduce the disparities in morbidity and mortality experienced by this population.