Global Mental Health: Globalization and Hazards to Women’s Health

1. Global Mental Health: Globalization and Hazards to Women’s Health Anne E. Becker, M.D., Ph.D., Sc.M. October 15, 2009 SW 25

2. Global Mental Health Delivery Challenges: Quick Reprise & Overview Resource and allocation gaps • Suboptimal health financing and inequitable distribution • “Clinico-centric services” • Child mental health policy gap • Understanding their relation to social processes and to vulnerable & “undervisible” populations (e.g., women and adolescents) • Research & information gap • Operationalization of social predictors of risk & resilience • Assessment of mental illness outcomes

3. Global Mental Health Delivery Challenges: Quick Reprise & Overview Limitations of quantitative assessment • Uncertain validity of measurement • Selection and reporting biases (method and topic-dependent) • Perils of reductionism • Ethnocentrism, bias, and limited local relevance

4. Global Mental Health Delivery Challenges: Quick Reprise & Overview Limitations of mental health assessment • Uncertain fit of universal nosologic categories with local worlds and relevance • Implications for screening, prevalence estimates, relevance of interventions developed for other populations • Not only illness, but impairment, distress, course, and outcomes may be culturally particular Possible strategies to circumvent limitations?

5. Global Mental Health Delivery Challenges: Quick Reprise & Overview Limitations of qualitative assessment of mental health data • Disentangling signal from noise: the inherent “messiness” of field data • Imperfect access to inner experience • Positioned subjects • Limits to causal inference • Balance of action with scholarship

6. What about globalization and mental health? • What causal mechanisms link economic and social change to impact on health? • Who is vulnerable? • Social processes and associated health risks are dynamic

7. Why study mental health in Fiji? • Fiji is undergoing rapid social and economic change • Opportunity to understand impact of social adversity

8. How do we measure impact of socio-cultural environment on mental health?

9. Studies relating acculturation to eating pathology (n=29) Becker et al, 2009

10. What are relevant dimensions of acculturation?

11. Studies relating acculturation to eating pathology (n=29) Becker et al, 2009

12. Results of an exploratory factor analysis of items relating to 5 dimensions of *acculturation* Becker et al, in press

13. Intercorrelations among 12 dimensions of *acculturation* Note: *p<.05, **p<.01; ***p<.001; Traditional adherence dimensions shaded in light grey; overlapping traditional dimension cells shaded in dark grey. Note: ** p<.01; ***p<.001; Ethnic Fijian cultural dimensions are shaded in light grey; overlapping Ethnic Fijian cultural dimension cells are in shaded in dark grey. (Becker et al, in press)

14. Outcome misclassification • LeGrange and colleagues (2004) investigated the validity of high EAT-26 scores among impoverished black adolescents in South Africa

15. Outcome misclassification • EDE-Q was used as a gold standard for validation and was consistent with no eating disorder diagnosis in 2 of 5 study participants • Their response relating to food preoccupation turned out to have related to their poverty and hunger, not an eating disorder

16. Anorexia Nervosa without Fat Phobia • Lee and colleagues described anorexia nervosa without fat phobia in the 1990s • EAT-26 misclassified non fat phobic individuals as not having an eating disorder when they apparently did (Lee et al. 2002)

17. Eating Disorders as biosocial phenomena • Cultural diversity in aesthetic ideals • and what they mean

18. Eating Disorders as biosocial phenomena: Weight management behaviors are constrained by the social environment

19. Eating Disorders as biosocial phenomena Cultural diversity in idioms of distress and rhetoric for self-expression

20. Can flexibility be built into classification?

21. Should ‘Non-Fat Phobic AN’ be Included in DSM-V?

22. Meta-analysis comparing AN with NFP-AN d = .27, p = ns (Becker, Thomas, & Pike, 2009)

23. Meta-analysis comparing AN with NFP-AN d = .65, p = .002 Significant difference holds even when constructs with no potential for overlap with fat phobia are excluded from the meta-analysis (d = .41, p = .04). (Becker, Thomas, & Pike, 2009)

24. DSM-IV Eating Disorder Categories Not Useful for Classifying Potential Cases Source and relevant discussion in: Thomas JJ, Crosby RD, Wonderlich SA, Striegel-Moore RH, Becker AE. A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: Evidence of cross-cultural variation in phenomenology. Under review at Psychological Medicine.

25. Required reading?

26. Etic perspective Universalizing versus local classification • The “outsider” perspective • Assumes a universal framework for illness • Attempts to identify the “true” core illness despite variations in epiphenomena

27. Emic perspective Universalizing versus local classification • The “local” perspective • Assumes a culturally particular and relativistic frame • Begins from the “ground up” with indigenous nosologic categories

28. An indigenous perspective on food refusal: Macake

29. An indigenous perspective on an illness episode: Macake Peri-orbital cellulitis Delirium Weight loss High fever Seizure Food Refusal

30. An indigenous perspective on an illness episode: Macake Bacterial meningitis Peri-orbital cellulitis Delirium Macake Weight loss High fever Seizure Food Refusal

31. An indigenous perspective on food refusal: Macake

32. An indigenous perspective on food refusal: Macake

33. Cultural Norms vs. Symptoms Is binge-eating relative to its context?

34. Cultural Norms vs. Symptoms Is purging relative to its context?

35. So, in the universe of possible ED symptoms, where do we draw the line? Binge-eating Purging Weight loss Anorexia nervosa?/ EDNOS? Excess shape concern Food Refusal

36. Where do we draw the line? Bulimia nervosa?/ EDNOS? Binge-eating Purging Weight loss Excess shape concern Food Refusal

37. Where do we draw the line? Binge-eating Purging Weight loss Macake? Excess shape concern Food Refusal

38. Encompassing cultural diversity in DSM-V another empirical approach

39. Indigenous Herbs Facilitate Culturally Normative Purging • Purging with indigenous Fijian herbs reported in focus groups • Using herbs to induce vomiting or diarrhea, or clean out the stomach, is socially acceptable in Fiji • Added items to EDE and EDE-Q to assess herbal purgative use

40. LPA Identified Two Classes with Different Methods of Purging Multiple purging class (37%) (Data from Thomas et al, under review)

41. LPA Identified Two Classes with Different Methods of Purging Multiple purging class (37%) Herbal purging class (63%) (Data from Thomas et al, under review)

42. Herbal and Multiple Purging Classes Have Similar Levels of Eating Pathology EDE-Q Global a b b F = 13.72, p< .001, error bar = SE (Data from Thomas et al, under review)

43. Herbal and Multiple Purging Classes Have Similar Levels of Dysphoric Affect CES-D a b b F = 5.88, p< .01, error bar = SE (Data from Thomas et al, under review)

44. Herbal Purging Class Exhibits Greater Impairment Than Multiple Purging Class CIA a a b F = 6.12, p< .01, error bar = SE (Data from Thomas et al, under review)

45. Conclusions about Eating Disorder Nosology from Fiji No, despite high rates of individual ED symptoms, DSM-IV categories did not detect any eating disorder cases • Are DSM-IV eating disorder categories useful for classifying potential cases in Fiji? • Yes, latent profile analysis identified two classes associated with impairment and pathology: • Multiple purging class • Herbal purging class • Can a more culturally sensitive and locally meaningful classification be empirically derived through latent profile analysis?

46. Eating Disorders: Can the DSM V have Global Clinical Utility? • Attunement to diverse cultural patterning of symptoms and local social norms • Locally valid assessment of population and individual risk • Consideration of emerging risk in populations undergoing rapid economic transition • Emphasis of fluidity of social norms

47. School-based study on Social change & health risk behaviors

48. School-based study on Social change & health risk behaviors

49. Back story narrative: Violence and despair • 117 (23%) girls reported seriously considering killing themselves in the past year • 15% (80) girls reported a physical attack in the past year

50. Suicide From: http://www.who.int/mental_health/prevention/suicide/evolution/en/index.html