What is Med Ed?

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When it comes to medications for mental illness, my 25 years of experience tells me that you can only assume one thing with reasonable accuracy: people have strong feeling about taking medications for mental illness. I’m a professor of psychiatry and a pharmacist. A lot of what I do is meet with families to speak with them, individually or in support groups, to talk about medications for mental illness. While no two stories are the same, there are a few common themes, for example concerns about side effects, becoming dependent (“addicted”) and a wish for more effective medications – finding that magic pill. 
There are widely available resources (written and electronic) that provide information about medications for mental illness (the so-called psychotropic medications), but what they provide is information not the ability to make an informed treatment decision. To do this requires selecting and combining the right information that fits the context of the full “story”. What is the diagnosis? Is it a classic picture of this diagnosis or is there a lot of uncertainty about it? What other health problems (mental and physical) exist? What past treatments, medications and otherwise, have been tried? What were the experiences with those treatments? What personal supports are in place? What is the individual’s preferred options and why?   There is only one way that I know of that helps people make informed medication decisions and it is not by giving them a bunch of reading, it is by giving them information that is relevant and putting that information in context. Then they are armed to truly participate in the decision. It is with this in mind that Med Ed was conceived.   
The first of its kind, Med Ed is for people who are thinking about or are already taking medications for mental illness or related symptoms. It includes answers to common and less common questions about these medications as well as checklists and other tools to make tracking symptoms, activities, and side effects easy. Brief information is provided about medications known as antidepressants, antipsychotics, anti-anxiety and sleep medications, stimulants, and mood stabilizers. There are tools to help keep track of the medications, by name, dose, and directions, and a glossary to help understand the many different terms.
Nearly every component of Med Ed encourages dialogue and a team approach to making decisions and for monitoring how the treatment is going. It provides mental health medication education and treatment tracking for people of all ages. It was originally developed, in English and French, by Drs. Murphy, Gardner, and Kutcher of Dalhousie University in collaboration with the Ontario Centre of Excellence for Child and Youth Mental Health at CHEO.  Now, in collaboration with the Multicultural Mental Health Resource Centre at McGill University, new versions of Med Ed have been developed in Arabic and Chinese.

Med Ed was created using the best available evidence regarding use, design, impact of medication resources and management of mental illness. The intention is to provide patients, their families, and health care providers with information and tools about medications for mental illnesses that help them work together to better plan and track the effects of the medications. Unlike most health and medication information resources, Med Ed encourages face-to-face discussions involving patients, families, and health providers so that the most important issues get discussed.
For more information about Med Ed, please visit http://medicationinfoshare.com

David Gardner
Professor of Psychiatry and Pharmacy
Dalhousie University

Med Ed is available on this website in English, French, Arabic and Simplified Chinese.

Podcast: MedEd (in Arabic)

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Dr. Yasser Ad-Dab’bagh discusses the Arabic version of MedEd, a booklet which helps teenagers with mental health issues to understand their medication and its side effects and to help them track their side effects, symptoms and changing dosage.

Article: Potential Contributions of Cultural-Clinical Psychology to a Revisioned Psychiatry

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Potential Contributions of Cultural-Clinical Psychology to a Revisioned Psychiatry

Andrew G. Ryder, Ph.D.
Department of Psychology, Concordia University
Culture and Mental Health Research Unit, Jewish General Hospital

Yulia E. Chentsova-Dutton, Ph.D.
Department of Psychology, Georgetown University

Cultural psychiatry has long aspired to be more than a subdiscipline of psychiatry, but rather a superordinate perspective that ideally would inform all of mental health research and practice. As mainstream psychiatry is by no means so informed at present, cultural psychiatry necessarily offers a necessary critique. This critique is vital, but it is not enough – it must be accompanied by aspiration, by an alternative vision of what psychiatry ought to be. We will argue here that a revisioned psychiatry is inherently interdisciplinary, and that psychology has an important contribution to make. Cultural psychiatry is in a good position to promote this interdisciplinarity, as it has been conceived this way for decades. The role of psychology is uncertain, however. While psychologists and other disciplines are involved, sometimes deeply, cultural psychiatry is predominantly a collaboration between psychiatrists and anthropologists. One problem is that the psychological approach, both theoretically and methodologically, can be an uncomfortable fit with cultural psychiatry. There are many reasons for this, but central among them is the relative inattention to culture and local context in mainstream psychology, paralleling some of the problems in mainstream psychiatry.

We believe that a revisioned psychiatry demands a revisioned psychology – a contextual psychology that responds to key anthropological critiques and yet remains psychology. We have recently proposed ‘cultural-clinical psychology’ as one such revisioned psychology (Ryder, Ban, & Chentsova-Dutton, 2011). Conceived as a blend of cultural and clinical psychologies, cultural-clinical psychology follows cultural psychology in positing that mind and culture ‘make each other up’ (Shweder, 1990). In keeping with emerging trends in clinical psychology, cultural-clinical psychology further posits that a similar statement can be made about mind and brain. Each level is understood broadly and can be extended, for example: brain to the nervous and endocrine systems; mind to commonly used external tools and close others; culture to artifacts and social institutions. Concepts such as ‘symptom’, ‘syndrome’, ‘trait, and ‘resilience’ are here understood as system properties, rather than residing at a particular level (Chentsova-Dutton & Ryder, in press; Ryder, Dere, Sun, & Chentsova-Dutton, in press). The result is a revisioned psychology, dedicated both to research and to clinical practice, that conceptualizes culture-mind-brain as a single system with multiple, mutually constitutive, levels.

Achieving this ambitious goal will obviate the need for the specifier ‘cultural’. Cultural-clinical psychology would become clinical psychology, as cultural psychiatry would become psychiatry (and cultural psychology would become psychology). Given broader trends strongly favouring biological approaches, however, cultural aspects are emphasized in contrast. For now, the potential contributions of cultural-clinical psychology to a revisioned psychiatry will be evaluated through generativity – does this perspective add new ideas, pointing to new research, leading in turn to new clinical interventions? A full consideration of this question is well beyond our scope here, so we will content ourselves with a single example. We believe the best psychology researchers concern themselves with explanation through underlying processes. This concern could be brought to bear on many of the generative but vaguely specified ideas used in cultural psychiatry. Take for example the ‘symptom pool’, proposed by medical historian Edward Shorter (CITE). The idea that different historical eras and – by extension – cultural contexts have specific symptom pools upon which people draw to convey distress has wide applicability and explanatory power. Psychologists want to know: how does this actually work?

What follows is a psychologically plausible model of the symptom pool. Each claim is supportable through psychological research, although very little research to our knowledge has specifically been designed for this purpose. We begin with the idea that the universe accessible to our perceptions is so complex that we can only attend to that which is meaningful (Peterson). This complexity includes many symptom constituents – experiences that could potentially become symptoms. Indeed, the background noise of such experiences is much greater than we generally realize, including physical sensations, stray thoughts, emotional fluctuations, and interpersonal disturbances, transient dissociations, and even brief quasi-psychotic experiences. Cultural scripts can then help us understand how we navigate this complexity in meaningful ways, some of which pertain to how potentially symptomizable experiences are to be understood. The symptoms themselves emerge in part due to feedback loops: attention to particular experiences increases the frequency and severity of these experiences. Out of the background noise of daily life, or the background chaos of an incipient crisis, emerge full-blown symptoms: pathological system properties of culture-mind-brain (Ryder & Chentsova-Dutton, 2012).

This approach points to research designed to establish the various phases of this psychological model in specific cultural contexts, with specific symptoms and syndromes. Can it also impact directly on clinical practice? To begin with, psychological assessment techniques need to tap into locally relevant symptom pools. If successful, psychology will contribute psychometric rigour, as well as a growing arsenal of methods that range far beyond traditional self-report questionnaires (Ryder et al., 2011). Beyond symptoms, a psychological process model of the symptom pool can guide us to assess the relevant cultural schemas operating in a particular sufferer’s local world. This could lead to techniques designed to assess both the meanings and practices endorsed by a particular person, and also their assumptions about the meanings and practices considered normative in their local worlds. We should also consider how we might assess the loops that generate and maintain symptoms. One possible approach to this might be the ‘chain analysis’ technique used in cognitive-behavioural therapy (CBT), in which a clinician works collaboratively with a client to unpack the event sequences that promote and maintain pathology. Here, successful assessment points the way towards potentially successful treatment.

We believe that knowledge of local symptom pools and the ways in which they operate can direct us to specific clinical interventions. First, by opening up possibilities for discussion, there is the potential to build rapport. Second, and more importantly for our purposes here, a study of the loops operating in the client’s culture-mind-brain provides entry points for intervention. Importantly, these entry points do not have to take place at the same level at which we conceptualize a given problem. Just as a pill can change social behaviours, so too can a psychological intervention change the brain (Ryder et al., 2011). In this case, interventions targeting specific loops have the potential to interrupt a pathological pattern in the culture-mind-brain. Much of this work is already being done in contemporary CBT, as well as in family systems therapy, but attention to the symptom pool broadens our understanding of the different ways this can happen. As befits a discipline committed to research and clinical work, these clinical possibilities require careful evaluation. Generativity in theory and research, with practical benefits for assessment and treatment, are central to the making the case for a cultural-clinical psychology that will make lasting contributions to an emerging revisioned psychiatry.

New book: Cultural Consultation

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The MMHRC is pleased to share news of the release of a new book edited by members of the MMHRC steering comittee. Cultural Consultation: Encountering the Other in Mental Health Care is edited by Laurence Kirmayer, Jaswant Guzder, and Cécile Rousseau and is published by Springer.

Cultural diversity is a global challenge for mental health services. The changing demography of communities requires rethinking approaches to cultural competence for health professionals and institutions. Cultural consultation is a way to improve the quality of mental health care by providing a nuanced understanding of the predicaments that prompt diverse clients to seek help, and the social contexts of their mental health problems, to guide clinical assessment and intervention.

Cultural Consultation explores the practice of cultural consultation as a strategy to improve the quality of mental health care for diverse populations. The contributors, who have worked together at an innovative clinical service, frame best practices in psychiatry clinical psychology, and social work in relation to empathy, human rights, and culturally responsive and ethically sound care. A detailed model of the process of cultural consultation, from initial intake, through assessment, to recommendations and referrals, provides guidelines for clinical practice. Expert contributors examine specialized settings (medical, psychiatric emergency, inpatient, social/legal services), populations (remote, indigenous, child and youth), and contextual issues in the care of people with a wide range of mental health problems.

Numerous case examples, charts, and tools add depth for readers interested in developing similar services or enhancing existing practice. Among the key areas covered:

  • Working with interpreters and culture brokers.
  • Family systems in cultural consultation.
  • Gender, power, and ethnicity in cultural consultation.
  • Consultation and mediation with racialized and marginalized communities. Collaborative care and primary care consultation.
  • Cultural consultation with refugees.

A unique guide to challenges and opportunities in contemporary practice, Cultural Consultation will be immediately useful for health care professionals, clinical psychologists, and cultural consultants and provide a versatile knowledge source for years to come.

Introduction: The Place of Culture in Mental Health Services.- Development and Evaluation of the Cultural Consultation Service.- The Process of Cultural Consultation.- Cultural Consultation in Child Psychiatry.- Working with Interpreters.- Culture Brokers, Clinically Applied Ethnography and Cultural Mediation.- Family Systems in Cultural Consultation.- Gender, Power & Ethnicity in Cultural Consultation.- Community Consultation and Mediation with Racialized and Marginalized Minorities.- Addressing Cultural Diversity Through Collaborative Care.- Consultation to Remote and Indigenous Communities.- Cultural Consultation for Refugees.- Consultation to Youth Protection and Legal Settings.- Cultural Consultation in General Hospital Psychiatry.- Cultural Consultations in Medical Settings.- Conclusion: The Future of Cultural Consultation.
To review sample pages of the book, please visit the book’s website.