Religious considerations

Mental health can be socially constructed and socially defined; that is, different professions, communities, societies and cultures have very different ways of conceptualizing its nature and causes, determining what is mentally healthy, and deciding what interventions are appropriate. Thus, different professionals will have different cultural and religious backgrounds and experiences, which may impact the methodology applied during treatment.Many mental health professionals are beginning to, or already understand, the importance of competency in religious diversity and spirituality. The American Psychological Association explicitly states that religion must be respected. Education in spiritual and religious matters is also required by the American Psychiatric Association.

Sociology is a branch of the social sciences that uses systematic methods of empirical investigation and critical analysis to develop and refine a body of knowledge about human social structure and activity, sometimes with the goal of applying such knowledge to the pursuit of social welfare. Its subject matter ranges from the micro level of face-to-face interaction to the macro level of societies at large.Sociology is a broad discipline in terms of both methodology and subject matter. Its traditional focuses have included social relations, social stratification, social interaction, culture and deviance, and its approaches have included both qualitative and quantitative research techniques. As much of what humans do fits under the category of social structure or social activity, sociology has gradually expanded its focus to such far-flung subjects as the study of economic activity, health disparities, and even the role of social activity in the creation of scientific knowledge. The range of social scientific methods has also been broadly expanded. The "cultural turn" of the 1970s and 1980s brought more humanistic interpretive approaches to the study of culture in sociology. Conversely, the same decades saw the rise of new mathematically rigorous approaches, such as social network analysis.

Related disability

Genetic studies have indicated that genes often play an important role in the development of mental disorders, via developmental pathways interacting with environmental factors. The reliable identification of connections between specific genes and specific categories of disorder has proven more difficult.Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections, to substance misuse, and to general physical health.Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as cognitive and emotional processes, personality, temperament and coping style.

Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.

Culture

Different societies, cultures, and even different individuals within a single culture may disagree as to what constitutes optimal or pathological biological and psychological functioning; and indeed research has demonstrated variation across cultures in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative within a particular culture does not necessarily mean it is conducive to optimal psychological functioning. Furthermore, while conceptions like incomprehensibility or bizarreness tend to be ubiquitous across cultures, determining exactly what qualifies as incomprehensible or bizarre is often ambiguous and subjective. These differences in determination can become highly contentious, especially with regards to religious, spiritual, or transpersonal experiences and beliefs. Such beliefs are typically not defined as disordered, especially if widely shared, despite meeting many criteria of delusional or psychotic disorders. Even when a belief or experience can be shown to produce distress or disability, the ordinary standard for judging mental disorders; the presence of a strong cultural basis is generally disqualifies it.

Clinical conceptions

Clinical conceptions of mental illness also overlap with cultural values and in the realm of morality and social behavior. So much so in fact, that it is sometimes argued that separating the two would be impossible without fundamentally redefining a person's role in society. In clinical psychiatry, persistent distress and disability indicate an internal disorder requiring treatment; but in another context, that same distess and disability can be seen as an indicator of emotional struggle and the need to address social and structural problems. This dichotomy has lead some academics and clinicians to advocate a postmodernist conceptualization of mental distress and well-being. Such approaches, along with cross-cultural and "heretical" psychologies centered on alternative cultural and ethnic identities and experiences stand in contrast to the mainstream psychiatric community's active avoidance of any involvement with either morality or culture.

Within the mental health community, the question of how to address the psycho-social interaction is an often contentious one. In recent years, some psychiatrists and psychologists have argued that current diagnostic standards tend to overstate or misinterpret neurophysiological findings and to understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only prove consistency, not legitimacy.

Cross-cultural

Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with the these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has opined that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.

Diagnosis

Many mental health professionals, particularly psychiatrists, seek to diagnose individuals by ascertaining their particular mental disorder. Some professionals, for example some clinical psychologists, may avoid diagnosis in favor of other assessment methods such as formulation of a client's difficulties and circumstances. The majority of mental health problems are actually assessed and treated by family physicians during consultations, who may refer on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview (which may be referred to as a mental status examination), where judgments are made of the interviewee's appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in relatively rare specialist cases neuroimaging tests may be requested, but these methods are more commonly found in research studies than routine clinical practice. Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations. It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice. Mental illness involving hallucinations or delusions (especially schizophrenia) are prone to misdiagnosis in developing countries due to the presence of psychotic symptoms instigated by nutritional deficiencies. Comorbidity is very common in psychiatric diagnosis, i.e. the same person given a diagnosis in more than one category of disorder.

Psychotherapy

Treatment and support may be provided in psychiatric hospitals, clinics or any of a diverse range of community mental health services. Often an individual may engage in different treatment modalities. A strong sense of being part of an interdependent society in developing countries makes the community-based treatment model the most effective mode of treatment. A combination of community-based treatment and the use of typical antipsychotic drugs have been found to yield the most positive, cost-effective results. Individuals may be treated against their will in some cases. Services in many countries are increasingly based on a Recovery model that supports an individual's personal journey to regain a meaningful life.

A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.

Medication

A major option for many mental disorders is psychiatric medication. There are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. There are a number of antidepressants beginning with the tricyclics, moving through a wide variety of drugs that modify various facets of the brain chemistry dealing with intercellular communication. Beta-blockers, developed as a heart medication, are also used as an antidepressant.

Anxiolytics are used for anxiety disorders and related problems such as insomnia.

Mood stabilizers are used primarily in bipolar disorder. Lithium carbonate (a salt) and Lamictal (an epileptic drug) are notable for treating both mania and depression. The others, mainly targeting mania rather than depression, are a wide variety of epilepsy medications and antipsychotics. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia. Although there has not been any evidence of the superiority of newer, atypical antipsychotic drugs, they are being prescribed to individuals throughout the world. The prescription of relatively cheaper, older typical antipsychotic drugs is also used.Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated.
There may also be off-label use of medications. There can be problems with adverse effects of medication and adherence.

The pharmaceutical industry

Recently, the pharmaceutical industry has come into severe criticism for hiding negative results from clinical trials from the public and the USFDA and for promoting medications for unapproved uses by pharmaceutical sales representatives. Prominent psychiatric researchers have also come under fire recently for failing to disclose drug company compensation which poses serious potential conflicts of interest with their research and professional activities.

Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. Psychosurgery is considered experimental but is advocated by certain neurologists in certain rare cases. Psychoeducation may be used to provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help groups for mental health and supported housing or supported employment (including social firms). Some advocate dietary supplements. Many things have been found to help at least some people. A placebo effect may play a role in any intervention.

Prognosis

Prognosis depends on the disorder, the individual and numerous related factors. Some disorders may be transient, while some may last a lifetime in some cases. Some disorders may be very limited in their functional effects, while others may involve substantial disability and support needs. The degree of ability or disability may vary across different life domains. Continued disability has been linked to institutionalization, discrimination and social exclusion as well as to the inherent properties of disorders.

Even those disorders often considered the most serious and intractable have varied courses. Long-term international studies of schizophrenia have found that over a half of individuals recover in terms of symptoms, and around a fifth to a third in terms of symptoms and functioning, with some requiring no medication. At the same time, many have serious difficulties and support needs for many years, although "late" recovery is still possible.

The WHO

The WHO concluded that the findings joined others in "relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the 20th century." Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks, and nearly all achieve it within two years, with nearly a half regaining their prior occupational and residential status in that period. However, nearly a half go on to experience a new episode of mania or major depression within the next two years. Functioning has been found to vary, being poor during periods of major depression or mania but otherwise fair to good, and possibly superior during periods of hypomania in Bipolar II.

Despite often being characterized in purely negative terms, some mental states labeled as disorders can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy. In addition, the public perception of the level of disability associated with mental disorders can change

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• Religious considerations
• Related disability
• Culture
• Clinical conceptions
• Cross-cultural
• Diagnosis
• Psychotherapy
• Medication
• The pharmaceutical industry
• Prognosis
• The WHO
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