Person:

Weiss, Mitchell

Belief in the role of Karma explains a variety of Phenomena in India. For a traditional medical system such as Ayurveda, the conflict between simultaneously held beliefs in fatalism and the efficacy of medical interventions poses an interesting dilemma that the tradition has taken pains to consider. Caraka Samhita discusses the role of karma as a determinant of the qualities and personality of the individual, lifespan, etiology of illness, and otherwise personality of the individual, lifespan, etiology of illness, and otherwise incomprehensible epidemics. Such speculations produce practical solutions to the dilemma, and these solutions in turn enhance the medical doctrine.

The medical texts by Caraka and Susruta describe the symptoms, etiology, theory, treatment and prognosis of four types of mental disorders-unmada, bhutonmada, apasmara, and murcha. The present discussion is restricted to unmada-its theory, treatment and prognosis with an indication of the scope of analysis with reference to the Western psychiatric nosology.

Stigma is a recognized barrier to early detection of HIV and causes great suffering for those affected. This paper examines HIV-related stigma in rural and tribal communities of Maharashtra, an area of relatively high HIV prevalence in India. The study used a mix of qualitative and quantitative methods to compare adult women and adolescents in a rural area, women in a rural area, and women in a tribal area. The respondents included 494 married women and 186 adolescents in a rural community and 49 married women in six tribal villages. HIV-related stigma was prevalent in all communities and was the highest among tribal and older respondents. High-risk behaviour was reported in both areas, accompanied with denial of personal risk. Our findings suggest that HIV may be spreading silently in these communities. To our knowledge, this is the first community-based study to make an in-depth assessment of HIV-related stigma in rural and tribal areas of India. By situating our findings within the broader discourse on stigma in the national and state-level data, this study helps explain the nature and persistence of stigma and how to address it more effectively among subcultural groups in India.

Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during the 2009–2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural Pune, India in 2012–2013. Semi-structured explanatory model interviews were administered to community residents (n=436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk, problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas. Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access, complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for effective vaccine action.

Context: Development of the cultural formulation interview (CFI) in DSM‑5 required validation for cross‑cultural and global use. Aims: To assess the overall value (OV) of CFI in the domains of feasibility, acceptability, and utility from the vantage points of clinician‑interviewers, patients and accompanying relatives. Settings and Design: We conducted cross‑sectional semi‑structured debriefing interviews in a psychiatric outpatient clinic of a general hospital. Materials and Methods: We debriefed 36 patients, 12 relatives and eight interviewing clinicians following the audio‑recorded CFI. We transformed their Likert scale responses into ordinal values – positive for agreement and negative for disagreement (range +2 to −2). Statistical Analysis: We compared mean ratings of patients, relatives and clinician‑interviewers using nonparametric tests. Clinician‑wise grouping of patients enabled assessment of clinician effects, inasmuch as patients were randomly interviewed by eight clinicians. We assessed the influence of the presence of relatives, clinical diagnosis and interview characteristics by comparing means. Patient and clinician background characteristics were also compared. Results: Patients, relatives and clinicians rated the CFI positively with few differences among them. Patients with serious mental disorders gave lower ratings. Rating of OV was lower for patients and clinicians when relatives were present. Clinician effects were minimal. Clinicians experienced with culturally diverse patients rated the CFI more positively. Narratives clarified the rationale for ratings. Conclusions: Though developed for the American DSM‑5, the CFI was valued by clinicians, patients and relatives in out‑patient psychiatric assessment in urban Pune, India. Though relatives may add information and other value, their presence in the interview may impose additional demands on clinicians. Our findings contribute to cross‑cultural evaluation of the CFI.

Rates, demographics and diagnostics, which are the focus of many studies of suicide, may provide an insufficient account without adequate consideration of psychological, social and cultural contexts and motives. Furthermore, reported explanations of suicide are shaped not only by events but also the relationship of survivor respondents explaining the suicide. An explanatory model interview for sociocultural autopsy has been used to assess underlying problems and perceived causes. This study in a low-income community of Mumbai in 2003–2004 compared accounts of the closest family survivors and more distant relationships. Our study design distinguished series-level agreement (i.e., consistency of accounts within a group) and case-level agreement for particular cases. Serious mental illness was the perceived cause reported by a respondent in either group for 22.0% of index suicides, but case-level agreement was only 6.0%. Regarding financial stressors, more closely related family respondents focused on acute stressors instead of enduring effects of poverty. Case-level agreement was high for marital problems, but low for other sources of family conflict. Tension was a feature of suicide reported in both groups, but case-level agreement on tension as a perceived cause was low (kappa = 0.14). The role of alcohol as a perceived cause of suicide had high series level agreement (46.0% in both groups) and case-level agreement (kappa = 0.60), suggesting comparable community and professional views of its significance. The study shows that it is relevant and feasible to consider general community patterns and particular survivor interests. Findings from this study recommend an approach to sociocultural autopsy to assess reasons for suicide in community studies. Findings clarify diverse views of underlying problems motivating suicide that should be considered to make mental health care more effective in assessing risk and preventing suicide.

Illness-related stigma is a complex and important issue, and its social impact contributes to a hidden burden of many health problems. Mitigating effects of stigma are a priority for mental health policy, especially for schizophrenia. Although numerous studies document its impact on patients and their families, health studies of stigma typically regard it in global terms without adequate attention to the conceptual and practical importance of sociocultural contexts and the particular features of illness that evoke stigma. Research at a psychiatric referral center in Bangalore, India, studied the cultural epidemiology of schizophrenia and stigma in interviews with family caretakers of 60 patients, using a locally adapted EMIC interview and the Positive and Negative Symptom Scale. An index of 13 stigma queries based on Goffman's formulation covered relevant aspects and proved to be internally consistent (Cronbach alpha = 0.81). Multivariate statistical regression and qualitative analysis of narratives were used to analyze this stigma index and identify explanatory variables based on cultural patterns of distress (PD), perceived causes (PC), and previous help seeking (HS). Significant variables included suspiciousness and inappropriate sexual behavior (PD), heredity and bad deeds (PC), and informal help seeking (HS). Previous allopathic help seeking was negatively associated with stigma. Analysis of coded text segments from respondent narratives showed how these variables were related to family-perceived stigma, with reference to marriage practices, moral meanings of schizophrenia, and ways in which effective allopathic care minimized stigma. Findings identify features of schizophrenia-related stigma in India, contribute to comparative culture studies, and inform practical approaches to mitigate stigma through community awareness and improved mental health services.

In addition to herbal and other traditional medicines, healers and healing temples are seen as providing curative and restorative benefits. In India many people troubled by emotional distress or more serious mental illnesses go to Hindu, Muslim, Christian, and other religious centres. The healing power identified with these institutions may reside in the site itself, rather than in the religious leader or any medicines provided at the site. Studies of these healing sites have focused primarily on ethnographic accounts.5 Research has not systematically examined the psychiatric status of the people coming for help at these religious centres or the clinical impact of healing. It has focused primarily on possession and non­psychotic disorders, rather than serious psychotic illnesses. Yet people with serious psychotic illnesses do visit such healing temples in India,6 and understanding the role of these institutions may help with planning for community mental health services in underserved rural areas.We describe here the work of a Hindu heal­ing temple in South India known as a source of help for people with serious mental disorders.We also tried to measure the clinical effectiveness of religious healing at this site.

Public responses to depression have a powerful effect on patients’ personal experience of illness, the course and outcome of the illness, and their ability to obtain gainful employment. Mental illness-related stigma reduction has become a priority, and to be effective, it requires innovative and effective public mental health interventions informed by a clear understanding of what stigma means. Based on Goffman’s formulation as spoiled identity, local concepts of stigma were validated and compared in clinical cultural epidemiological studies of depression in Bangalore, India, and London, England, using the EMIC, an instrument for studying illness-related experience, its meaning, and related behaviour. Similar indicators were validated in both centres, and the internal consistency was examined to identify those that contributed to a locally coherent concept and scale for stigma. Qualitative meaning of specific features of stigma at each site was clarified from patients’ prose narrative accounts. Concerns about marriage figured prominently as a feature of illness experience in both centres, but it was consistent with other indicators of stigma only in Bangalore, not in London. Although stigma is a significant issue across societies, particular manifestations may vary, and the cultural validity of indicators should be examined locally. Analysis of cultural context in the narrative accounts of illness indicates the variation and complexity in the relationship between aspects of illness experience and stigma. This report describes an approach following from the application of cultural epidemiological methods for identifying and measuring locally valid features of stigma in a scale for cultural study, cross-cultural comparisons, and for baseline and follow-up assessment to monitor stigma reduction programmes.