In the Journals

In the Journals, March pt. II

To round out articles of interest from the March journals…..Enjoy!



This month, BioSocieties presented a volume guest edited by Margaret Sleeboom-Faulkner and Bob Simpson on experimental ethics, using an internationally comparative eye towards ethical practices.


Precarious ethics: Toxicology research among self-poisoning hospital admissions in Sri Lanka (Salla Sariola and Bob Simpson)

This paper examines clinical trials of an antidote to be used against individuals who have poisoned themselves. The trials took place in Sri Lanka in 2008 and 2009, where high numbers of individuals inflict self-harm through poisoning. Sariola and Simpson argue that we can think of the victims in three different positions: as abjects, as objects, and as subjects. The victims of self-poisoning are abjects in that they have marginalized themselves by attempting to kill themselves, thus placing themselves on the fringe of society. However, it is through this very subject position of abjection that an individual has the opportunity to become the object of research and experimentation, in a system bounded by ethical guidelines that view these individuals as subjects. Broadly, Sariola and Simpson explore the relationship between self-harm and personhood in the context of human subject research and medical clinical trials, which they view as messy states of exception. Thus, they “set out to observe closely the conduct of the trial in order to gain insight into the way that ethics is performed in this precarious context” (42). They take as their ethnographic site the moment when an individual who has poisoned himself is poised to transition from abject to object/subject: the moment when he is asked to participate in the clinical trial. They use this moment to interrogate the ethics at play in the decision to participate: “It is not about self-harm or suicide as such, or the experiences of these patients and their families, but about the ways in which humanitarian interventions, randomised control trials and human subject research are brought together in novel configurations and guided by an ethics, which circumstances dictate as precarious” (43). They conclude that the clinical trial forms a particular state of exception in which the object/subject is actually humanized, rather than dehumanized: “within the normative codes that govern human subject research there is an expectation that the patient will move from a state of abjection to one of dignity and respect through the process of becoming a research participant. Here, falling within an experimental gaze does not result in dehumanisation, as it did within the concentration camps, but rather its opposite, the possibility of recognition as an autonomous and rights-bearing agent.” (54).


Discursive dialects of bioethics: Understanding the institutional embeddings of human stem cell experimentation in India (Prasanna Kumar Patra and Margaret Sleeboom-Faulkner)

Patra and Sleeboom-Faulkner examine experimental stem cell therapy (ESCT) in India, questioning how it is that ESCT is so commonly available despite legal prohibition and little scientific evidence in favor for its efficacy. They ask how providers survive in this environment. The answer has to do with the (unfounded) hope ESCT provides patients with incurable disease> Patra and Sleeboom-Faulkner primarily contend that ESCT providers survive through bionetworking, or “informal forms of socio-scientific and entrepreneurial liaison” (75).


Latent science collaboration: Strategies of bioethical capacity building in Mainland China’s stem cell world (Margaret Sleeboom-Faulkner)

In this article, Sleeboom-Faulkner looks at how international standards in scientific research and collaboration have molded Mainland China’s domestic regulations and practices. She posits the idea of latent collaboration for “collaborations that are not (yet) noticeable or developped” (9). She sees these types of latent collaborations between Chinese and international scientists. The paper is interview- and fieldwork-based, extending from interviews of over 40 scientists in mainland China between 2006 and 2008. Sleeboom-Faulkner further seeks “to show that the structural dynamics of economic inequality in the global economy can only partly explain regulatory permissiveness in the life sciences in China….a main problem is that emergent collaborations hinge on an increasingly widespread moral economy expressed in the values of ethically and scientifically schooled staff, the development of academic networks, the creation of biomedical ethics committees, science exchange agreements, and in what counts as scientific achievements in international peer-reviewed journals” (8).


Culture, Medicine, Psychiatry

Same and Different in Trans-Local East Asian Medicine (Judith Farquhar)

Farquhar offers the first of two introductions to a special section in this Culture, Medicine, Psychiatry devoted to the study of mental illness in East Asian Medicine. She begins with the following questions: “Why should medical anthropologists be interested in East Asian traditional medicine? Especially, we might ask, why should anyone–clinician or anthropologist– care about the history of the abstruse knowledge and highly technical practice that have been ‘traditional’ in China, Japan, and Korea?” (105) She answers that clinicians and anthropologists ought to care as discussions of East Asian Medicine bring forward conversations of the universality and/or locality of the body, disease, and medicine. All of these issues acquire intensified meaning in the context of the study of globalization, shifting our answers from epistemological difference to practical similarity. She is interested in “what kind of knowing is most salient in medical practice” and suggests that we “think away from the ‘problem’ of differences and ask whether some kinds of sameness might also inform a trans-local anthropology of medicine– historically, epistemologically, clinically, experientially” (108).


Constraint as a Window on Approaches to Emotion-Related Disorders in East Asian Medicine (Volker Scheid)

Scheid too writes opening remarks for the set of papers addressing East Asian Medicine. His introduction and research begins with seeing depression as an epidemic and the DSM as system of exporting Western categories: “Far from objectively assessing mental health they seek to shape specific ways of citizenship and of being a person that, rather conveniently, match the western neoliberal economic order. Displacing modes of dealing with mental health issues that emphasize interpersonal relationships or social and economic causes, depression thus becomes just one more condition that reflects and sustains globally dominant networks of consumption and control in the twenty first century” (2). Scheid sees this process as a two way street. While the DSM and ICD export Western categories, popular Western demand now forces biomedicine to exist alongside complementary and alternative medicines. The set of papers that follows treats East Asian medicine as a unified field not to overstate national traditions, but rather the emphasize a shared use of constraint in dealing with emotion-related disorders.


Treating Emotion-Related Disorders in Japanese Traditional Medicine: Language, Patients and Doctors (Keiko Daidoji)

Daidoji looks at how popular understandings of illness shape traditional Japanese medicine (Kampo), specifically by tracing the changing meaning of constraint (utsu) in Kamp. During the Edo poeriod, utso referred to emotion-related disorders. Western medicine spread throughout Japan during the Meiji period and neurasthenia replaced utsu as the primary emotional disorder. Daidoji examines how doctors innovated in response to the new disease categories, by focusing on Wada Tõkaku’s practice during the Edo period and then looking at Yomuto Kyūshin and Mori Dõhaku, Kampo doctors in the early twentieth century who oriented their practice to neurasthenia rather than the utsu.


Stories to Be Told: Korean Doctors Between Hwa-byung (Fire-Illness) and Depression, 1970-2011 (Soyoung Suh)

Suh probes the construction of hwa-byung, or Koreans’ emotion-related disorder, in which Koreans draw upon both a traditional notion of “constrained fire” and the DSM’s “depressive disorders” to create and amalgam category. Suh is particularly attuned to how this categorical mélange reflects Korea’s self-positioning within a global context: “Whereas the label of hwa-byung initiated the indigenous turn during the 1980s, now the term succinctly responds to the recent trend of exploring the colloquial dimension of medicine” (81).


The Excitations and Suppressions of the Times: Locating the Emotions in the Liver in Modern Chinese Medicine (Eric I. Karchmer)

Karchmer explores how doctors of Chinese medicine borrow from theories of  “constraint” to treat emotion-related disorders: “How do doctors of Chinese medicine treat a psychiatric condition, such as depression, when their is no such disease category in their medical practice?” (8). Karchmer uses two historical periods to answer this question, the first being the 1920s and 1930s, when “leading scholars of Chinese medicine were engaged in a critical and experimental reexamination of the entire corpus of traditional medical knowledge” as a result of the encounter with imperialism and the rise of Japan as a superpower (10). Then he turns to the 1950s and 1960s when scholars “were focused on identifying the key characteristics of Chinese medicine and promoting the methodology of bianzheng lunzhi” (10) in a moment of Chinese institution building and reunification.


The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology (Joseph D. Galanek)

Galanek examines staff narratives of mental illness in an American prison to see how staffers construct psychiatric illness amongst inmates. How does comorbidity confound categorical construction? Galanek questions how categories cross along DSM axes, addiction, and structural issues of social pathology such as histories of homelessness and street violence. He is primarily attuned to diagnostics and how practitioners apply a diagnostic to something so multifaceted as mental illness: “Thick accounts of the examination reveal significant aspects of how these diagnostic acts are embedded within institutional contexts. In attending to such processes, I draw attention to the indeterminacy of inmate subjectivities and behaviors which prison mental health clinicians attempt to ‘objectify’ and how these clinical complexities create diagnostic uncertainties and thus problematize psychiatric knowledge” (197). He argues that in a system of multi diagnostic meanings, “[c]ontext becomes a critical component of diagnostic processes, and staff recognize that behaviors may be challenging to interpret and that the diagnostic process is complicated by how inmates respond and react to the prison environment” (219).


Doing Resilience with ‘Half a Brain:’ Navigating the Moral Sensibilities 35 Years After Hemispherectomy (Andrew R. Hatala, James B. Waldram, and Margaret Crossley)

Hatala, Waldram, and Crossley work closely with two disabled adults who underwent hemispherectomies as children due to severe seizure disorders. The authors treat their everyday actions as ads of resilience, conceptualizing resilience as “the individualized intentional actions which disabled, distraught, or at risk individuals perform in contextually relevant and idiosyncratic ways as they navigate health and well-being within their local social and moral worlds” (148).


Opening the Gift: Social Inclusion, Professional Codes and Gift-Giving in Long-Term Mental Healthcare (S.T.C. Ootes, A.J. Pols, E.H. Tonkens, D.L. Willems)

Deinstitutionalization has made destigmatization and social inclusion part of the community mental heath care professional’s job. This paper examines how the professional obligation to socially include a mentally ill individual sometimes clashes with other professional obligations– in this case, the act of gift-giving from patient to professional. Accepting a personal gift would be an act of social inclusion, but violates other professional codes of ethics. Based on 2007-2008 fieldwork from a Dutch mental health care facility, the authors ask “what types of gifts do clients of mental healthcare give to their care professionals, and how do these gifts relate to professional codes and the objective of social inclusion?” (133).



We Want to See Our King’: Apparitions in Messianic Habad (Yoram Bilu)

Rabbi Menachem Mendel Shneerson died in 1994, but members of the messianic Hasidim (meshichistim) report seeing apparitions of the late Rabbi. Bilu uses a cognitive model of misattribution to explain these apparitions through the “messianic ecology cultivated by the meshichlistim to make the absent Rabbi present” (98). Bilu further distinguishes apparition from vision, hallucination, and visualization.


Border Children: Interpreting Autism Spectrum Disorder in South Korea (Roy Richard Grinker and Kyungjin Cho)

Grinker and Cho examine the decision of many Korean mothers to resist a DSM diagnosis of Autism Spectrum Disorder (ASD) for their children. These mothers accept that their children are different, but use fundamentally different categories than the DSM to characterize their children. Where the DSM sees a spectrum, Korean mothers see a border zone, instead calling their children ‘border children’ (gyonggye-seon aideul). They see their children as being socially awkward, isolated, and sometimes with unusual interests, but view these differences in a social, rather than biomedical, frame. Particularly in light of the common academic successes of these children, their issues are seen as only falling within the  social domain. Yet by rejecting a DSM label, these mothers place themselves in a bureaucratic bind: “By choosing to resist a diagnosis of ASD they were also rejecting clinical and special education services, because delivery of those services in South Korea is contingent on a DSM diagnostic label. Yet some of them did take their children to private social skills programs, as these lessons were considered a form of play, rather than clinical therapy or special education. We are concerned in this article with how and why mothers make these choices” (49).


Power Struggles: The Paradoxes of Emotion and Control among Child-Centered Mothers in the Privileged United States (Diane M. Hoffman)

Hoffman looks at the notion of the “power struggle” between parent and child as a cultural trope amongst economically advantaged mothers of preschool and elementary school-aged children in the Mid-Atlantic US. She argues that the “power struggle” trope ““encodes important insights concerning culturally situated notions of power, selfhood, and emotional control” (76). As such, she uses the “power struggle” as a way of examining parenting values and how parenting practices form the identities of both mothers and children.


All That is Just Ersatz: The Meaning of Work in the Life of Immigrant Newcomers (Sveta Roberman)

Roberman studies how employment (or underemployment) shapes to lives of middle- to late-middle-aged Jewish immigrants who moved to Germany following the collapse of the Soviet Union. Roberman “underscores the arena of work as playing a formative role in the creation of immigrants’ self-perceptions and identities,” arguing “that experiences originating in the work sphere have a strong impact on the nature of the immigrant-host relationship” (2). In other words, other forms of marginalization extend from the social stigma associated with being an immigrant unable to secure a formal job, perpetuating the immigrant’s sense of being a newcomer or foreigner.


Change and the Construction of Gendered Selfhood among Mexican Men Experiencing Erectile Difficulty (Emily Wentzell)

Working in the context of machismo, “a patriarchal style of masculinity characterized by virility, womanizing, and emotional withdrawal” (24), whether as a rascist sterotype, passe reality, or current cultural norm, Wentzell explores the role of erectile difficulty in the construction of masculinity. She interviewed 250 older, working class urology patients in the Mexican city of Cuernavaca who were experiencing ED as a result of their urological condition. The interviewees expressed a recognition of a shift in how manliness is expressed as men age, becoming more centered on family and less on sexual activity. Wentzell brings in a conversation of selfhood by examining how ED medication is used by men to create a different identity.



Medication communication during ward rounds on medical wards: Power relations and spatial practices (Wei Liu, Elizabeth Manias, and Marie Gerdtz)

Liu, Manias, and Gerdtz focus on communication surrounding medication management through the routinzed practice of rounding, “sites where key decisions are made about initiating, continuing, altering, or ceasing medications” (114). The authors conducted ethnographic fieldwork at two medical wards in a teaching hospital in Melbourne. Their analysis of discursive power in medication management takes on a spatial dimension; physicians come out of their offices to the patients bedside, while nurses primarily work in open-floor units in public. Physicians can move to the bedside and away from it, acquiring the power to determine when the patient is relevant and when not. The epitome of this spatial distribution of power is the private group conversation that occurs somewhat informally amongst physicians and to which other members of the medication decision making team (nurses, pharmacists, patients) are not privy.


Troubling stoicism: Sociocultural influences and applications to health and illness behavior (Andrew Moore, Janet Grime, Paul Campbell, and Jane Richardson)

This paper interrogates the relationship between stoicism and pain. Studies have found that patient stoicism actually inhibits only the reporting of mild and weak pain, with no effect on the reporting of severe or moderate pain. Moore et al take this as an indication that stoicism has its limits. They attempt to identify this limit by filling in the gap in the study of stoicism vis-à-vis chronic illness. They conclude that there is a danger that applying a label of stoicism may in fact only serve to hinder the questioning of illness behaviours which might otherwise benefit from further exploration. We would suggest that a more considered exploration of the context in which the term stoicism is used is important to furthering an understanding of how people cope with and manage chronic illness, particularly painful health conditions. Silence in the face of ill health and pain is not necessarily a marker of stoicism, and the basis and reason for an individual’s silence should warrant closer scrutiny” (170).


‘I just want to be normal’: An analysis of discourses of normality among recovering heroin users (Sarah Nettleton, Joanne Neale, and Lucy Pickering)

Locating their work within a population of heroin addicts for whom life is difficult, the authors examine what it means when addicts utter the common refrain “I just want to be normal.” Ultimately, they suggest that “this benign aspiration is in fact an emblematic feature of modern society. The articulation of a desire to be normal is, we argue, not simply a personal goal but the product of a society that encourages and privileges normality” (175). The authors explore these issues using a Foucauldian lens that emphasizes social compliance and subjectivity through tactics of governmentality. Normal must be understood alongside the abnormal. The social construction of this binary pushes individuals to desire falling within the normal camp. The self-assertion of normality falls within a sociopolitical frame: “’I just want to be normal is a politically, socially, and psychologically loaded aspiration” (188).


How ‘alternative’ is CAM? Rethinking conventional dichotomies between biomedicine and complementary/alternative medicine (Ana M. Ning)

Ning uses the explosion of interest in complementary/alternative medicine (CAM) in Canada and elsewhere as an opportunity to ask what exactly is meant when CAM practices are siphoned off from the biomedical. For Ning, CAM is perceived as dichotomous to biomedicine and is associated with “ideologies such as holism, vitalism, spirituality, natural healing, and individual responsibility” (136). Yet the increased demand for CAM therapies in contexts that are predominantly biomedical brings into question what happens to CAM when it is embraced by the mainstream. Ning examines the categories of CAM and biomedicine against binary oppositions through an integrated sociological paradigm that “approaches all micro and macro social phenomena in terms of a continuum entailing dialectical interrelationships between material realities (e.g. Society, bureaucracy, technology, law) and non-material processes (e.g. Beliefs, values, norms, perceptions). Using this theoretical lens, I contend that the so called alternative ideologies are integral aspects of biomedicine as well as socially and culturally dominant values, norms and practices related to health and health care” (137).



International Journal of Social Psychiatry

Depression and the medicalization of sadness: Conceptualization and recommended help-seeking (Glòria Durà-Vilà, Roland Littlewood and Gerard Leavey)

Background: Critiques of the validity of the DSM diagnostic criteria for depressive disorder argue that it fails to dif- ferentiate between abnormal sadness due to internal dysfunction or depression (sadness without an identifiable cause), and normal sadness (sadness with a clear cause).
Aims and Methods: A population survey was undertaken in adult education centres in Spain aiming to explore beliefs about depression and normal sadness. Two hypothetical case vignettes portrayed individuals experiencing deep sadness, both fulfilling criteria for major depressive disorder (DSM-IV), one with a clear cause, the other without an identifiable cause. Three hundred and forty-four (344) questionnaires were obtained (95% response rate).
Results: Participants statistically significantly differentiated between the sadness-with-cause vignette, seen more fre- quently as a normal response, while the one without a cause was seen as pathological. Help-seeking behaviour recom- mendations followed this distinction: a medical option was statistically significantly more common when there was no cause for sadness. Socio-cultural variation in how people understand and deal with sadness was also found.

Conclusions: This study emphasizes the importance of taking into account the context in which depressive symptoms occur as it seems that the absence of an appropriate context is what makes people conceptualize them as abnormal. It also raises questions about the lack of face validity of the current diagnostic classification for depressive disorder that exclusively uses descriptive criteria.


Burden of informal care giving to patients with psychoses: A descriptive and methodological study (Lena Flyckt, Anna Löthman, Leif Jörgensen, Anders Rylander, and Thomas Koernig)

Background: There is a lack of studies of the size of burden associated with informal care giving in psychosis.
Aims: To evaluate the objective and subjective burden of informal care giving to patients with psychoses, and to com- pare a diary and recall method for assessments of objective burden.
Method: Patients and their informal caregivers were recruited from nine Swedish psychiatric outpatient centres. Subjec- tive burden was assessed at inclusion using the CarerQoL and COPE index scales. The objective burden (time and money spent) was assessed by the caregivers daily using diaries over four weeks and by recall at the end of weeks 1 and 2.

Results: One-hundred and seven patients (53% females; mean age 43 ± 11) and 118 informal caregivers (67%; 58 ± 15 years) were recruited. Informal caregivers spent 22.5 hours/week and about 14% of their gross income on care-related activities. The time spent was underestimated by two to 20 hours when assessed by recall than by daily diary records. The most prominent aspects of the subjective burden were mental problems.
Conclusion: Despite a substantial amount of time and money spent on care giving, the informal caregivers perceived the mental aspects of burden as the most troublesome. The informal caregiver burden is considerable and should be taken into account when evaluating effects of health care provided to patients with psychoses.


A study of acculturation in psychotic and non-psychotic immigrants living in Athens (F. Gonidakis, E. Lembesi, V.P. Kontaxakis, B.J. Havaki-Kontaxaki, D. Ploumpidis, M. Madianos, and G.N. Papadimitriou)

Background: Acculturation is the phenomenon that results when a group with one culture comes into continuous contact with a host culture.
Aims: To investigate the correlation between acculturation and psychotic symptomatology in a group of immigrants suf- fering from psychosis and to explore differences in demographic factors related with the acculturation process between individuals with and without psychosis.
Methods: Sixty-five patients and 317 non-psychotic immigrants were interviewed using the Immigrant Acculturation Scale (IAS) and a structured questionnaire for demographic data. The Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Glοbal Assessment of Functioning (GAF) were also administered to all immigrants suffering from psychosis.
Results: Total IAS scores, as well as IAS everyday life scores, were positively correlated with GAF scores. IAS everyday life score in the patient group related with religion, marital status, gender and years in Greece, while in the non-psychosis group it was related with gender and years in Greece. IAS wishful orientation/nostos (the strong desire for one’s home- land) related with religion in both groups. The IAS identity in the psychosis group did not show any significant relation with any of the variables, while in the non-patient group, it was related with marital status, gender and years in Greece. Age, duration of residence in Greece and higher adoption of Greek ethnic identity were the variables that differentiated the two groups of immigrants.
Conclusion: Acculturation in immigrants suffering from psychosis could be seen as a process that does not correlate strongly with the severity of the symptomatology but is probably influenced by different set of factors.


A comparison of female migrant workers’ mental health in four cities in China (Xuesong He and Daniel Fu Keung Wong)

Background: There are approximately 47.5 million female migrant workers living in major cities in China. Numerous studies have documented the marginalized living conditions confronting migrant workers in cities, such as employment difficulties, unjustifiably demanding working conditions, lack of medical insurance and social provision, poor housing conditions, unfavourable educational arrangements for migrant children, and discrimination by urban residents. In addition, female migrant workers may suffer from discrimination, exploitation and oppression.
Aim: This study aimed to explore the difficulties and perceived meaningfulness of migration and their effect on the mental health status of female migrant workers in Shanghai, Kunshan, Dongguan and Shenzhen.
Methods: A total of 959 female migrant workers from 12 factories completed the questionnaires, which included the Brief Symptom Inventory, the Migration Stress Scale and the Meaning in Migration Scale.
Results: The findings indicate that 24% of female migrant workers could be classified as having poor mental health and the percentage in Shenzhen (35%) was far greater than in the three other cities in China. ‘Financial and employment- related difficulties’, ‘cultural differences’, gender-specific stressors and ‘better future for self and children’ significantly accounted for the mental health outcomes of female migrant workers.
Conclusion: Recommendations for policy change and service initiatives targeted at improving the mental health of female migrant workers are discussed.


Sources of parental burden in a UK sample of first-generation North Indian Punjabi Sikhs and their white British Counterparts (Helen Lloyd, Pratima Singh, Rowena Merritt, Adarsh Shetty, Swaran Singh, and Tom Burns)

Objective: The correlates of parental burden in schizophrenia may differ between ethnic groups, but few studies have examined this in a UK setting. Our aim was to identify the correlates of burden in a UK sample of first-generation North Indian Punjabi Sikh parents and their white British counterparts.
Method: Test the association of burden with a series of clinical, social and service use variables and control for potential confounding factors in a model predicting drivers of burden in a combined sample of the above.
Results: The strongest correlates of burden were patient symptoms and parental distress. Differences in correlates of burden between the groups emerged when individual components of service use and parental social network were tested. The group comparisons also revealed differences in expressed emotion (EE) and social networks.
Conclusion: The similarities in sources of burden between the groups could be explained by a commonality of socio- cultural and economic experience, resulting from the successful acculturation and affluence of this British Sikh group. The differences between the groups may be related to enduring cultural factors such as kin support, since larger family groups were associated with low burden in the British Sikh group. The nature of EE in this British Sikh group may explain why it was not associated with burden in this sample.


The uncut jade: Differing views of the potential of expert users on staff traingin and rehabilitation programmes for service users in Hong Kong (Roger M.K. Ng, Veronica Pearson, Yin Wan Pang, N.S. Wong, N.C. Wong, and F.M. Chan)

Background: Service user participation in direct service provision and evaluation has been developing in the western world in the past 20 years. However, this recovery-based care model is relatively new in Asia.
Aim: To understand the views and perceptions of the service users and of psychiatric nurses about the recruitment of peer specialists in a regional psychiatric unit in Hong Kong.
Method: A qualitative study using probe questions to understand the above issues in the form of focus group discus- sion. A total of 13 psychiatric nurses and 16 mental health service users were recruited from a regional psychiatric unit for the study.
Results: Content analysis based loosely on grounded theory has identified several important themes. While service users are generally enthusiastic about the potential contribution of peer specialists in a service setting, they are much concerned about rejection and discrimination by the psychiatric staff. Psychiatric nurses are also sceptical about the involvement of peer specialists in the delivery of service, although for an entirely different set of reasons. In view of the divergent views of the service users and the psychiatric nurses, a second round of focus group discussion was conducted seven months later to understand whether the themes distilled were consistent with their views expressed in the first round of focus group discussion.
Conclusion: It is encouraging is that, for those psychiatric nurses who worked with volunteer service users in the pilot scheme of ‘expert user participation’, there was a change in view towards positive acceptance about peer specialist involvement in service delivery. The study provides some insight into the potential obstacles to and opportunities in the implementation of peer specialist services in routine psychiatric services in Hong Kong.


Lessons from the 2004 Asian tsunami: Epidemiological and nosological debates in the diagnosis of post-traumatic stress disorder in non-Western post-disaster communities (A.P. Rajkumar, T.S.P. Mohan, and P. Tharyan)

Background: The nosological validity of post-traumatic stress disorder (PTSD) remains controversial in non-Western communities. After natural disasters, epidemiological studies often overlook these conceptual debates and assess post- traumatic stress symptoms (PTSS) by short screening instruments. Such PTSS estimates are reported as inflated prevalence rates of PTSD in post-disaster settings.
Aims: To discuss the prevalence and determinants of PTSS within the context of pertinent epidemiological and nosological debates.
Methods: We assessed PTSS and grief symptoms of 643 survivors from five Indian villages struck by the Asian tsunami using the Impact of Events Scale – Revised and Complicated Grief Assessment Scale. We adopted a case control design and employed complex sample multiple logistic regression statistics to study the determinants of PTSS.
Results: The prevalence of PTSS was 15.1% (95% CI 12.3%–17.9%). PTSS was significantly associated with traumatic grief, female gender, physical injury, death of children and financial losses, but not with functional disability (p = .91).

Conclusions: Although PTSS were common in this population, elevating them to a psychiatric construct of PTSD is questionable, when functional impairment and avoidance behaviours were absent. Grief reactions, socio-economic burden, and poor support systems contribute towards PTSS. We highlight the important issues regarding the nosological validity and epidemiology of PTSD in non-Western communities.


Patient participation in mental healthcare: When is it difficult? A qualitative study of users and providers in a mental health hospital in Norway (Marit Solbjør, Marit By Rise, Heidi Westerlund, and Aslak Steinsbekk)

Background: In western countries, patient participation is requested in policies on mental health services. Participation is built on ideas of democracy and individual responsibility. Mental illness has, however, been characterized by its irrational features.
Aim: To investigate mental health service users’ and providers’ views on patient participation during episodes of mental illness.

Methods: Qualitative interview study with 20 users and 25 staff from a mental health hospital in central Norway.

Results: Both users and professionals saw poor illness phases as an obstacle to patient participation. Lack of insight, lack of verbal ability and difficulty cooperating made participation difficult. During such phases, patient participation was redefined.There was a shift in responsibility where professionals took charge through strategies of providing information, motivating patients and reducing choices. Respect and dignity were maintained and not redefined.
Conclusions: In poor phases of mental illness, patient participation was redefined and weighed against what was perceived to be the patient’s best interest.


Gender differences in the psychological impact of tsunami (Biju Viswanath, Ami S. Maroky, Suresh B. Math, John P. John, Anish V. Cherian, Satish C. Girimaji, Vivke Benegal, Ameer Hamza, and Santosh K. Chaturvedi)

Aim: The aim of this observational study was to explore gender-related differences in psychiatric morbidity during the initial three months following the December 2004 earthquake and tsunami involving the Andaman and Nicobar Islands, India.
Methods: There were 12,784 survivors sheltered across 74 relief camps with 4,684 displaced survivors in Port Blair and 8,100 non-displaced survivors in Car-Nicobar Island. All persons who accessed mental health assistance within the camps constituted the study sample. Diagnoses were made by qualified psychiatrists using the ICD-10. There were 475 patients: 188 (40%) men and 287 (60%) women.
Results: There were significant gender differences in terms of displacement. There were significantly higher levels of panic disorder, unspecified anxiety disorder and somatic complaints in the displaced women while the non-displaced population showed more adjustment disorder.
Conclusions: Displacement was a significant factor in the manifestations of observed pathology. Displaced women had greater psychiatric morbidity. In addition, the fact that adjustment disorder (a self-limiting disorder form of psychopa- thology) was more prevalent in the non-displaced group may be a reflection of the findings of overall lesser morbidity in non-displaced women. Hence, women may have to be rehabilitated in their own habitats after major disasters.

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