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Mental health for all: A wise investment

Across the globe, the ongoing COVID-19 pandemic has infected millions, and left even more struggling to not only cope with the fear of morbidity and mortality stemming from the infection itself, but also reeling from the abrupt dissolution of our normal routines, inundation with contradictory and politicized public health messages, loss of employment or housing, isolation from family and friends, disrupted access to schools, child care, and other community facilities and services.  On top of that, additional stressors are felt by health care professionals and other essential workers, and those with limited access to COVID-19 protections and other resources.

The significant challenges brought by the pandemic this year underscore the fact that that no one is immune to experiences that challenge one’s mental health and underscores that access to both physical and mental health care is critical.   However, there is a mismatch between those most at risk of experiencing illness and access to adequate care, with COVID-19 is disproportionately impacting racial and ethnic minority groups, and refugee and migrant populations face stigma and barriers to healthcare access that may increase risk.

Each year October 10th is recognized as World Mental Health Day, encouraging reflection on how we can better promote global mental health.  The year’s theme designated by the World Federation For Mental Health is “Mental Health for All: Greater Investment – Greater Access” to emphasize the need to make mental health care a staple of quality health care, accessible by all.  

Below, PLOS Medicine Associate Editor Caitlin Moyer highlights some recently published articles that shed light on recent advances in mental health among populations where greater investment and greater access are needed.

Mental health in refugees and migrants

Refugees and those seeking asylum are at high risk of mental illness resulting from traumatic experiences and exposure to stressors.  Gaining a better understanding of the prevalence of mental health issues among refugee and asylum seeking populations worldwide will allow resources in host countries to be better applied to addressing health care needs.  Challenges and limitations of previous reports of mental illnesses among refugee individuals relate to the diversity of refugee experiences, countries of origin, and circumstances of displacement.  Thus, Blackmore et al sought to determine updated estimates of the prevalence of mental illness among refugee and asylum seeker populations by conducting a systematic review of the current evidence.  The review included twenty-six studies conducted across 15 countries, representing a total of 5,143 adult refugees and asylum seekers.  Strengths of the assessment, which built upon previous reports of mental illness prevalence in refugee populations, included the inclusion of studies assessing mental illness with clinical interviews or validated assessment scales.  

            The authors found that rates of both posttraumatic stress disorder and depression are approximately 30%, higher than rates reported for the population in general.  In contrast, rates of anxiety disorders and psychosis were not different from the prevalence reported in the general population.  Importantly, the results indicated that rates of PTSD and depression were not different in those displaced longer than 4 years.  In light of this finding, the authors note that providing access to both early and ongoing mental health care, beyond the period of initial resettlement, is critical for promoting the mental health of refugees and asylum seekers.

Psychotherapy for mental illness

While many psychotherapy practices geared toward treating mental illness in refugees aim at reducing symptoms, it may be helpful to implement psychotherapy enabling refugees to take into account underlying psychosocial disruptions related to their own journeys that contribute to symptoms.  A cost-effective solution to delivering mental health interventions in resource limited settings is to train non-mental health professionals for this task.  In a randomized trial, Alvin Kuowei Tay and colleagues compared how cognitive behavioral therapy (CBT) compared to a new Integrative Adapt Therapy (IAT) program to improve mental health symptoms among Chin, Kachin, and Rohingya persons displaced to Malaysia. Both IAT and CBT therapies were conducted over 6 weekly sessions. The authors assessed symptoms of PTSD, Complex PTSD (CPTSD), Major Depressive Disorder (MDD), as well as the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor–Davidson Resilience Scale [CDRS]). The results 6 weeks after the treatment was delivered indicated that while both CBT and IAT were effective, IAT delivered by lay counsellors resulted in improvements in mental health, adaptive stress compared to CBT therapy.

Although it is important to note that the follow up duration was only 6 weeks, and the findings may not generalize to other refugee populations, the findings of this study imply that IAT is effective in reducing symptoms and promoting adaptive capacity among refugees and further investigation is warranted to test whether IAT exerts long lasting reductions in mental illness symptoms.

Housing insecurity, substance use and mental health

In addition to refugee populations, people who are living in uncertain housing situations or who are homeless are at increased risk of illnesses, substance use disorders and mental illnesses, including psychotic disorders.  Psychosocial risk factors among homeless or marginally housed populations may contribute to mental health risks.  In a recent study by Andrea Jones and colleagues, researchers met monthly with more than 400 participants living in precarious housing or experiencing homelessness in Vancouver, Canada, over an average of 6 years, to investigate relationships between substance abuse, infection status, and risk of psychosis, and how these factors relate to early mortality.  The results suggested that a past diagnosis of psychotic disorder, experience of recent trauma, methamphetamine, alcohol, and cannabis use were factors related to risk of psychotic features.  

The results suggested that the relationship between psychotic features and mortality risk differed between those older and younger than 55 years.  In younger participants, past psychotic disorder increased the risk of mortality, but this was not observed in older participants.  The authors conclude that an approach that might mitigate psychosis risk would be targeting substance use may decrease the risk for psychosis, and that effective treatment and prevention of psychosis could have a beneficial impact on the risk of mortality among those in marginalized housing situations.

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