Development and Its Vicissitudes – A Review of "Pluriverse: A Post-Development Dictionary"

Eliot Sorel, MD
Founding Editor-in-Chief
Editorial Board
GlobalMentalHealth&PsychiatryReview,Vol.4No.1,Winter2023
ZONAL EDI
ZONAL EDIT
TORS
ORS
AFRICA
AFRICA
David M. Ndetei, MD, DSc,
David M. Ndetei, MD, DSc, Kenya
Kenya
Bonginkosi Chiliza,
Bonginkosi Chiliza, MBChB, FCPsych, PhD
MBChB, FCPsych, PhD,
, South Africa
South Africa
Victoria Mutiso, PhD,
Victoria Mutiso, PhD, Kenya
Kenya
ASIA/
ASIA/P
PACIFIC
ACIFIC
Y
Yueqin
ueqin H
Huang, MD, MPH, PhD,
uang, MD, MPH, PhD, China
China
R
Ro
oy Kalliv
y Kallivayalil, MD,
ayalil, MD, India
India
THE AMERICAS
THE AMERICAS
F
Fernando Lolas, MD,
ernando Lolas, MD, Chile
Chile
Vincenz
Vincenzo Di Nicola, MPhil, MD, PhD,
o Di Nicola, MPhil, MD, PhD, Canada
Canada
EUROPE
EUROPE
Fabian Kraxner, MD,
Fabian Kraxner, MD, Switzerland
Switzerland
Ruta Karaliuniene, MD,
Ruta Karaliuniene, MD, Germany
Germany
ASSOCIATE EDITORS
ASSOCIATE EDITORS
Victor Pereira-Sanchez, MD, PhD
Darpan Kaur Mohinder Singh, MBBS, DNB (Psychiatry)
Darpan Kaur Mohinder Singh, MBBS, DNB (Psychiatry)
TOTAL HEALTH INNOVATIONS SECTION
TOTAL HEALTH INNOVATIONS SECTION
Mansoor Malik, MD, MBA,
Mansoor Malik, MD, MBA, Editor
Editor
Chinwe E
Chinwe Eziokoli-Ashraph, MD,
ziokoli-Ashraph, MD, Associate Editor
Associate Editor
Darpan Kaur Mohinder Singh, MBBS, DNB (Psychiatry),
Darpan Kaur Mohinder Singh, MBBS, DNB (Psychiatry), Associate Editor
Associate Editor
Keneilwe Molebatsi, M
Keneilwe Molebatsi, MD,
D, Associate Edi
Associate Editor
tor
Victor Pereira-Sanchez, MD, PhD,
Victor Pereira-Sanchez, MD, PhD, Associate Editor
Associate Editor
Consuelo Ponce de Leon, MD,
Consuelo Ponce de Leon, MD, Associate Editor
Associate Editor
Daria Smirnova, MD, PhD,
Daria Smirnova, MD, PhD, Associate Editor
Associate Editor
G M H P
REVIEW
ISSN 2833-3004

Eliot Sorel, MD
Founding Editor-in-Chief
Volume 4, No. 1
Winter 2023
ISSN 2833-3004
ZONAL EDI
ZONAL EDIT
TORS
ORS
AFRICA
AFRICA
David M. Ndetei, MD, DSc,
David M. Ndetei, MD, DSc, Kenya
Kenya
BonginkosiChiliza,
BonginkosiChiliza,MBChB,FCPsych,PhD
MBChB,FCPsych,PhD,
,SouthAfrica
SouthAfrica
Victoria Mutiso, PhD,
Victoria Mutiso, PhD, Kenya
Kenya
ASIA/
ASIA/P
PACIFIC
ACIFIC
Y
Yueqin
ueqin H
Huang, MD, MPH, PhD,
uang, MD, MPH, PhD, China
China
R
Ro
oy Kalliv
y Kallivayalil, MD,
ayalil, MD, India
India
THE AMERICAS
THE AMERICAS
F
Fernando Lolas, MD,
ernando Lolas, MD, Chile
Chile
Vincenz
Vincenzo Di Nicola, MPhil, MD, PhD,
o Di Nicola, MPhil, MD, PhD, Canada
Canada
EUROPE
EUROPE
Fabian Kraxner, MD,
Fabian Kraxner, MD, Switzerland
Switzerland
Ruta Karaliuniene, MD,
Ruta Karaliuniene, MD, Germany
Germany
Associate Editor
Associate Editor
DarpanKaurMohinderSingh,MBBS,DNB(Psychiatry),
Associate Editor
Associate Editor
TOTA
TOTAL
L HEALTH
HEALTH INNOVATIONS
INNOVATIONS SECTION
SECTION
Mansoor Malik, MD, MBA,
Mansoor Malik, MD, MBA, Editor
Editor
ChinweEziokoli-Ashraph,MD,
ChinweEziokoli-Ashraph,MD,AssociateEditor
AssociateEditor
Associate Editor
Associate Editor
Keneilwe Molebatsi, MD,
Keneilwe Molebatsi, MD, Associate Editor
Associate Editor
VictorPereira-Sanchez,MD,PhD,
VictorPereira-Sanchez,MD,PhD,AssociateEditor
AssociateEditor
ConsueloPoncedeLeon,MD,
ConsueloPoncedeLeon,MD,AssociateEditor
AssociateEditor
Daria Smirnova, MD, PhD,
Daria Smirnova, MD, PhD, Associate Editor
Associate Editor
G M H P
REVIEW
REFERENCES
1. OECD (2014), Making Mental Health Count: The Social and Economic Costs of
Neglecting Mental Health Care OECD Health Policy Studies, OECD Publishing.
doi: 10.1787/9789264208445-en
Access to Health Care and Human Rights
Eliot SOREL MD
We chose to focus the current issue of our Review to Access to Care and Human
Rights, as nearly fifty percent of the world’s population lacks access to essential
health services and one hundred million may end up in poverty because of health
expenses, according to the World Health Organization.
Health, and access to healthcare across the lifecycle are essential for individuals’
and populations’ TOTAL Health, as well as an intrinsic component for national and
global security and prosperity across low-, middle- and high-income economies.
We also believe and have advocated that access to health care, inclusive of mental
health care, is a human right. We were pleased that the American Psychiatric Asso-
ciation (APA) Board of Trustees adopted this policy at the recommendation of the
APA Assembly of District Branches in 2017.
We hope that nations across economies will consider this high priority item and
adopt its implementation to the benefit of populations’ health and their nations’
economies. The Organization of Economic Cooperation and Development (OECD)
data of a few years ago, after the economic crisis of 2008, clearly indicates the im-
pact of health and illness on countries’ economies and viceversa (1).
Accomplishing universal access to health care, inclusive of mental health care, as a
human right, is necessary but insufficient. It must be complemented by reinventing
health care systems; systems that integrate well primary care, mental health and
public health in a TOTAL Health model; that are of quality, accessible throughout
the life cycle, are affordable, and sustainable.
Eliot Sorel, MD, Founding Editor-in-Chief

TABLE OF CONTENTS
The Global Mental Health and Psychiatry
Review (GMHPR) is a multidisciplinary
publication serving the Global Mental Health
Community. It welcomes original scholarly
contributions that focus on research, health
systems and services, professional education
and training, health policy, and advocacy with
a catalytic focus on TOTAL Health”
GMHPR is officially registered at the United
States Library of Congress, and published three
times a year around January (Winter issue), May
(Spring/Summer issue), and September
(Autumn issue).
Colleagues interested in contributing to future
issues should contact our Editor's Virtual Office
at gmhpreview@gmail.com, presenting a
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Submitted manuscripts should have not been
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Published materials at GMHPR should not be
partially or totally reproduced in any other
official publication without written permission
from our Editorial Office. GMHPR does not
charge publishing nor reading fees, and
published issues can be freely accessed and
shared with colleagues or the public providing
the publication's name, ISSN, and issue
details are maintained.
EDITORIAL:
Access to Health Care and Human Rights..............................................................i
AFRICA ZONE:
Expanding the Concept of Youth Mental Health and Access to Youth Mental
Health Services...............................................................................................................5
David Ndetei, MD, DSc, Victoria Mutiso, PhD
The Friendship Bench Zimbabwe - “Healing the Healers” Project.......................7
Rukudzo Mwamuka, MBCHB, MMED, Dixon Chibanda, MD,MMED,MPH,PhD
Violation of Rights of People With Mental Disorders and Governance of
Mental Health in Nigeria..............................................................................................8
Margaret Isioma Ojeahere, MBBS, FWACP
the AMERICAS ZONE:
Mental Health Literacy, Language, and Communication. The Case for
Vaccination Refusal......................................................................................................9
FernandoLolas,MD,IDFAPA
Understanding and Improving Global Education in Human Rights in Psychiatric
Training: The World Network of Psychiatric Trainees Initiative................................10
Victor Pereira-Sanchez, MD, PhD, İdil Kına, MD
ASIA/PACIFIC ZONE:
Access to Care in South India - Reaching the Unreached........................................12
Roy Abraham Kallivayalil, MD
Health Service Utilization in Patients With Mood Disorder in Chinese Adults......13
Yueqin Huang, MD, MPH, PhD
G M H P
REVIEW
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G M H P
REVIEW
EUROPE ZONE:
Interview with
Professor Dr. Danius Puras......................................................................................................14
Ruta Karaliuniene, MD
Migration Healthcare – Current Insights from Switzerland.................................16
Fabian Herbert Kraxner, MD
BOOK REVIEW
Development and Its Vicissitudes – A Review of Pluriverse: A Post-
Development Dictionary [Editors: Ashish Kothari, Ariel Salleh, Arturo
Escobar, Federico Demaria, & Alberto Acosta]...........................................................17
Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, DFAPA, FCPA, FACHS
GMHPR: BACK COVER
Save the Date in 2023: Upcoming Events.......................................................................20
TABLE OF CONTENTS
ISSN 2833-3004

© GLOBAL MENTAL HEALTH & PSYCHIATRY REVIEW, Vol. 4 No. 1, Winter 2023 5
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AFRICA
Expanding the Concept of Youth
Mental Health and Access to Youth
Mental Health Services
David Ndetei Victoria Mutiso
David Ndetei, MD, DSc1,2,3
Victoria Mutiso, PhD2,3
1
University of Nairobi, Nairobi, Kenya
2
Africa Mental Health Research and Training Foundation
(AMHRTF), Kenya
3
World Psychiatric Association Collaborating Centre for
Research and Training, Nairobi, Kenya
Most people (not all people) would consider that the youth
age range varies from early adolescence to about mid 20’s. For
operational purposes, this would include high school to college
and university undergraduate students. Going by these limits
for purposes of logistically viable implementation strategies,
we are then talking roughly from 14 to 24 years age range to
include high schools, colleges and universities. Needless to say,
this age group range consists of a substantial proportion of
the population. This would run into millions of youth in Low
and Middle Income Countries (LMIC), and millions of youth
if we take for example the 50 million population of Kenya and
even more in countries with larger populations. Many studies
including from Kenya have estimated that up to about 12% of
youth have depression and/or anxiety and a significant number
have other mental conditions including substance use disorder.
Any known type of mental disorder is found in all countries
including LMICs.
Pandemics like the just concluded COVID-19, threats
of other pandemics such as reoccurrence of COVID-19,
Ebola, etc., reports of violence and wars as already happening
in some parts of the World, or mere threats of these; the
worsening climate change; the high levels of bullying in schools,
cyberbullying, the high levels of suicide, etc., are some of the
known potential causes of stress in students. The list is almost
endless and continues to grow as new predictors of mental
health globally and regionally are unearthed using community/
public epidemiological studies. Against this background is
the huge dearth of “experts”, “professionals” that specialize
in mental health treatment of the youth. Given this scenario,
we cannot even think of access to clinical services for all or
on demand and in particular services and facilities modelled
after the operational models found in High Income Countries
(HICs). We would be talking about a very small number of
people who access these services. Instead, we should be talking
about presentation and promotion in addition to public and
clinical service management. Add to this the World Health
Organization (WHO) definition of health which incorporates
the concept of wellbeing and the need to enhance it.
All of these taken into account, then there is a need to re-
strategize, to be innovative and ask ourselves this very basic
question: what resources do we already have at our hands, even
as we develop more resources, including training of specialized
physical and human resources? We cannot throw up our hands
and say “We can do little because we have few resources. We
will have to wait until we catch up with those countries that have
the resources that we do not have”. This is what is called pity
partying. It will take undetermined time to catch up with what
HICs have at the moment and even when we will achieve that,
those countries will have moved to a high level of resources.
They are not sitting waiting for us.
So, what do we do? We have huge resources that we have not
exploited to the full and which resources have a high potential
to reach critical masses in a way that promotes mental health
wellbeing. This approach has the potential to promote health
seeking behavior to resources that have been demonstrated to
be evidence based in achieving enhanced wellbeing and some
effective interventions. These include the youth themselves – in
their millions through youth and peer-based interventions; the
thousands of teachers who can be trained to provide enhanced
awareness, wellbeing and promote health-seeking behavior;
the millions of parents and guardians who can equally and
similarly be given enhanced awareness of how mental health

© GLOBAL MENTAL HEALTH & PSYCHIATRY REVIEW, Vol. 4 No. 1, Winter 2023
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REFERENCES
1. Osborn TL, Venturo-
Conerly KE, Arango S, Roe
E, Rodriguez M, Alemu RG,
Gan J, Wasil AR, Otieno
BH, Rusch T, Ndetei DM.
Effect of Shamiri layperson-
provided intervention vs study
skills control intervention
for depression and anxiety
symptoms in adolescents in
Kenya: a randomized clinical
trial. JAMA psychiatry. 2021 Aug 1;78(8):829-37.
2. MutisoV,MusyimiC,TeleA,GitongaI,NdeteiD.Feasibilitystudyon
the mhGAP-IG as a tool to enhance parental awareness of symptoms
of mental disorders in lower primary (6-10 year old) school-going
children: Towards inclusive child mental health services in a Kenyan
setting.EarlyInterventioninPsychiatry.2021Jun;15(3):486-96.
3. NdeteiD,MutisoV,MarajA,AndersonK,MusyimiC,MusauA,Tele
A, Gitonga I, McKenzie K. Towards understanding the relationship
betweenpsychosocialfactorsandegoresilienceamongprimaryschool
children in a Kenyan setting: A pilot feasibility study. Community
MentalHealthJournal.2019Aug;55(6):1038-46.
4. David M. Ndetei, Victoria Mutiso, Isaiah Gitonga, Emeka Agudile,
Albert Tele, Lilian Birech, Abednego Musau. World Health
Organization life-skills training is efficacious in reducing youth
self-report scores in primary school going children in Kenya. Early
InterventioninPsychiatry.2018;1-9.DOI:10.11111/eip.12745.
5. Mutiso V., Musyimi C., Musau A., Nandoya E., McKenzie K.,
Ndetei D. Pilot towards developing a school mental health service:
Experiences and lessons learnt in implementing Kenya Integrated
intervention model for Dialogue and Screening to promote children›s
mental wellbeing (KIDS). Early Intervention in Psychiatry. 2018, 1-7.
DOI:10.1111/eip.12543.
6. Ndetei, D. M., Mutiso, V., Maraj, A., Anderson, K. K., Musyimi, C.
and McKenzie, K. (2016) ‘Stigmatizing attitudes toward mental illness
among primary school children in Kenya.’ Social psychiatry and
psychiatricepidemiology,51(1)pp.73–80.
7. Ndetei,D.M.,Mutiso,V.,Musyimi,C.,Mokaya,A.G.,Anderson,K.K.,
Mckenzie,K.andMusau,A.(2016)‘Theprevalenceofmentaldisorders
amongupperprimaryschoolchildreninKenya.’SocialPsychiatryand
PsychiatricEpidemiology,51(1)pp.63–71.
problems present and how they can be handled; the thousands
of community health workers and community facilities such
as health centres, and the increasing community-based
hospitals; the thousands of clergy who indeed are the first
contact by parents/guardians if they have a problematic child;
the thousands of community opinion leaders, etc. For the
avoidance of doubt, there can never be school mental health
without the involvement of the communities from which the
children are drawn.
In a nutshell, what we are saying is that we are not
poor in resources. But we need to be innovative. Mental
health for children – whether in schools or institutions – is
a multistakeholder, multidisciplinary responsibility, with
avenues for upwards as well as downward referrals. These can
run parallel even as we train specialists. It is a team approach.
We are not being just theoretical or merely rhetorical –
there is evidence that the above approaches can work. More
importantly, open interactive and mutually respectable
dialogues afford the opportunity to dialogue and agree on
solutions to barriers or even facilities to access the above
services; provide the opportunity for the people to understand
and appreciate the bio-psychosocial model in addition and with
respect to their models. The effect of this inclusive dialogue is
“evaporation of stigma”.
Art therapy, dance therapy and drama are very effective
tools that can be affected by training anybody interested
including lay people. This reminds us of the great work of
Fredrick Hickling who overcame generational trauma in
Jamaica’s school going children through drama. There are
many other well documented examples. In addition, all of the
above packages can be formatted into virtual learning to reach
critical masses.
In summary, it is possible to reach critical masses of youth
and provide interventions using already available resources
even as we develop others. The western model is not necessarily
the solution for us at least in unforeseeable nature. However,
we must be innovative. In other words, there is hope for the
mental health of our youth.

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AFRICA
The Friendship Bench Zimbabwe -
“Healing the Healers” Project
True to the initial predictions, there was a 25-27% increase in
mental health conditions such as stress, anxiety and depression
in the general population during the peak of the COVID 19 pan-
demic1,2
. It’s been three years but the psychological impact of the
pandemic is still being felt. Healthcare workers (HCWs) have been
disproportionately affected by the negative psychological impact of
COVID-19. Prior to the COVID-19 pandemic, there was already
concern about the high levels of burnout and emotional exhaus-
tion faced by HCWs due to the nature of their job and this was
exacerbated by the pandemic3
. Despite the lack of published data,
HCWs in poor-resource countries like Zimbabwe were not spared
by this mental health crisis. Several reasons contributed to the ex-
acerbation of burnout, stress, fear, anxiety and depression during
this period. These included lack of personal protective equipment,
increased workload, long working hours, poor remuneration and
strained relationship as the HCWs spent more time away from their
families in fear of infecting them4
.
It is against this background that the Friendship Bench em-
barked on a project to meet the psychological needs of the HCWs.
Despite a significant decline in COVID-19 infections after the third
wave, HCWs in Zimbabwe still had high levels of stress, burnout
and depression. The Friendship Bench adapted its Problem-Solving
Therapy model with the aim of having a dedicated mental health
service for HCWs. The Friendship Bench, Problem Solving Therapy
has successfully reduced symptoms of common mental disorders
such as depression and anxiety in the general population5
. The in-
tervention was initially piloted in Zimbabwe but has been adapted
for other populations in countries like Malawi, Zanzibar, Kenya and
the United States of America. This was the first time the interven-
tion was used to address mental health needs of HCWs.
Trained counsellors provided psychosocial support and Prob-
lem-Solving Therapy virtually using WhatsApp texts or voice calls.
This was done anonymously and free of charge. The intervention
reached 4,966 HCWs consisting of nurses, doctors, nurses aids,
pharmacists, radiographers and other auxiliary staff. Out of the
4,966 a total of 4,145 (83.4%) were screened using a locally validated
tool, the Shona Symptom Questionnaire (SSQ). Of those screened
1,083 (26,1%) showed signs of common mental disorder (CMD).
Of those showing signs of CMD there was an 80% improvement
as measured by SSQ. For the first time, HCWs felt appreciated by
having a dedicated service to cater for their mental health needs.
The HCWS could receive counselling sessions even in the comfort
of their homes using their mobile phones. Utilizing the virtual plat-
form for sessions also tried to reduce fear and stigma which is one
of the greatest barriers of taking up mental health services among
HCWs.
We might be in the post-pandemic era with low rates of infec-
tions in Africa but, the psychological impact of COVID-19 is still
with us. This brings an important lesson about pandemic prepared-
ness that we have had to learn over the last three years. Psychosocial
support and mental health services must be included as part of re-
sponse to any pandemic. This will mitigate the adverse psycholog-
ical effects of a pandemic, not only on the general population, but
also on HCWs who are often on the frontline.
Dixon Chibanda
Rukudzo Mwamuka, MBCHB, MMED1,2
Dixon Chibanda, MD,MMED,MPH,PhD1,2,3
1
Mental Heath Unit, Faculty of Medicine ,
University Of Zimbabwe, Harare, Zimbabwe
2
Friendship Bench Organization, Zimbabwe
3
Centre for Global Mental Health, London School of
Hygiene and Tropical Medicine, London
Rukudzo Mwamuka
REFERENCES
1. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress,
anxiety, depression among the general population during the
COVID-19 pandemic: a systematic review and meta-analysis.
Glob Health. 2020;16(1):57. doi:10.1186/s12992-020-00589-w.
2. Santomauro DF, Herrera AMM, Shadid J, et al. Global prevalence
and burden of depressive and anxiety disorders in 204 countries
andterritoriesin2020duetotheCOVID-19pandemic.TheLancet.
2021;398(10312):1700-1712. doi:10.1016/S0140-6736(21)02143-7.
3. Dubale BW, Friedman LE, Chemali Z, et al. Systematic review of
burnout among healthcare providers in sub-Saharan Africa. BMC
Public Health. 2019;19(1):1247. doi:10.1186/s12889-019-7566-7.
4. Chingono RMS, Nzvere FP, Marambire ET, et al. Psychological dis-
tress among healthcare workers accessing occupational health ser-
vices during the COVID-19 pandemic in Zimbabwe. Compr Psy-
chiatry. 2022;116:152321. doi:10.1016/j.comppsych.2022.152321.
5. Chibanda D, Weiss HA, Verhey R, et al. Effect of a Primary Care–
Based Psychological Intervention on Symptoms of Common
Mental Disorders in Zimbabwe: A Randomized Clinical Trial.
JAMA. 2016;316(24):2618-2626. doi:10.1001/jama.2016.19102.

8
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The increasing man made and nat-
ural catastrophes have amplified so-
cioeconomic problems and healthcare
inequalities predisposing more people
worldwide to mental health problems.
The 2022 report of the World Health
Organization on mental disorders
states that over 970 million people globally live with a form of men-
tal disorder1
. This population is vulnerable to human rights violations
and suffers infringement of civil, cultural, economic, political and so-
cial rights2
. The violation of rights of people with mental disorders is a
worldwide phenomenon albeit assumes different forms with varying
intensity from the arguably subtle negligence, coercion, inappropriate
use of medications and therapy to the more obvious institutionaliza-
tion, seclusions/ restraints, torture, physical assault and social exclu-
sion (limited educational opportunities denial of employment and
socialamenities,denialofmarriage/procreationandchildcareoppor-
tunities)2,3
. Evidence shows that these violations originate from stigma
and misconceptions fostered by ignorance, religious and cultural be-
liefs.4
Mental health related stigma is still rife globally and presents not
only as a contextual factor but also a form of human rights violations.
Despite the recognition of mental health rights as human rights and
measurestotackleviolations,theinfringementofrightsofpeoplewith
mental disorders spans family settings to institutions and systems and
variesacrosscountriesandculturesanditisaffectedbytheavailability
of such country’s resources4
. Moreover, the absence of mental health
laws has fueled human rights violations in some LMICs like Nigeria.
For several decades, Nigeria had been operating the lunacy act of
1958 which at its core encourages violation of rights of people with
mental disorders. It was a discriminatory act which did not recog-
nize the fundamental human rights of or protect people with mental
healthconditions,nordiditrecognizementalhealthrelatedstigmaas
a human rights violation. Therefore, it is unsurprisingly that acts such
as forced treatment, unlawful detention of the mentally ill in unsani-
tary and degrading conditions, chaining, torture, and physical/sexual
abuse perpetuated by untrained or undertrained persons were large-
ly unchecked in the country. Consequently, other factors in Nigeria
which make people with mental disorders susceptible to violations
suchaspoverty,poorknowledgeonmentaldisorders,apathytowards
mental health conditions, inadequate manpower and infrastructure,
wideningtreatmentgap,prohibitivecostoftreatment,andpoormen-
tal health funding remain barriers to the elimination of human rights
violations in this population.
Considering the inherent vulnerability of people with mental dis-
orderstohumanrightsviolations,itisimportantthatmeasureswhich
willcurbthismenaceareinstitutedandproperlyimplemented.There-
fore,itisnogainsaythatitwasaremarkablelandmarkeventinNigeria
onthe5th
ofJanuary2023,whenthefirstmentalhealthlawwassigned
following concerted and relentless efforts by psychiatrists, other men-
tal health professionals and key stakeholders. A law that promises to
securethewelfare,conferprotection,eliminatehumanrightsviolation,
and improve quality of life of people with mental disorders amongst
others5
. While this is a notable success for mental health, there is the
need to ensure that this law does not become just writings on a paper
that carries little or no weight, but one that promotes awareness with
results in attitude changes, improved budgetary allocation and fund-
ing, establishes mental health treatment facilities in rural and urban
areas, encourages community centered care, supports adequate man-
power/capacity building, and comprehensive mental health research.
Therefore, mental health professionals in Nigeria cannot afford to rest
ontheiroarsbutforgeontoensureproperimplementationofthisnew
lawiftheobligationoftheUnitedNationsConventionontheRightsof
PersonswithDisabilitiesandeliminationofhumanrightsviolationsof
people with mental disorders is to be achieved.
Margaret Isioma Ojeahere, MBBS, FWACP
Department of Psychiatry, Jos University Teaching
Hospital, Jos, Plateau State, Nigeria
REFERENCES
1. Mental Disorders. World Health Organization fact
sheets. 2022. Available online from https://r.search.yahoo.
com/_ylt=AwrErZ3WC8Rjy4osjylXNyoA;_ylu=Y29s-
bwNiZjEEcG9zAzEEdnRpZAMEc2VjA3Ny/RV=2/
RE=1673821270/RO=10/RU=https%3a%2f%2fwww.who.in-
t%2fnews-room%2ffact-sheets%2fdetail%2fmental-disorders/
RK=2/RS=tcZI61IzQWtKD2ih5MOD1rP3qEg-.
2. Anvar Sadath, Vranda Mysore Narasimha, Mukund Rao, Vijay
Kumar, Muralidhar D, et al. (2014) Human Rights Violation in
Mental Health: A Case Report from India. J Psychiatry 17: 120.
3. Muhia J, Jaguga F, Wamukhoma V, Aloo J, Njuguna S. A hu-
man rights assessment of a large mental hospital in Kenya.
Pan African Medical Journal. 2021;40:199. doi: 10.11604/
pamj.2021.40.199.30470.
4. Mfoafo-M’Carthy M, & Huls S. Human Rights Viola-
tions and Mental Illness: Implications for Engagement
and Adherence. SAGE Open. 2014; 4(1). https://doi.
org/10.1177/2158244014526209.
5. Ileyemi M. Buhari signs mental health bill after two failed at-
tempts.PremiumTimes.11Jan2023.Availableonlinehttps://r.
search.yahoo.com/_ylt=AwrEtzICRcRj2QkwoABXN-
yoA;_ylu=Y29sbwNiZjEEcG9zAzEEdnRpZAMEc2VjA3Ny/
RV=2/RE=1673835906/RO=10/RU=https%3a%2f%2fwww.
premiumtimesng.com%2fnews%2fheadlines%2f575072-bu-
hari-signs-mental-health-bill-after-two-failed-attempts.html/
RK=2/RS=oU86lIYisw8LSTl7FsVE5iDkCQ8-.
Violationof Rightsof PeopleWith
Mental Disordersand Governance
of Mental Health in Nigeria
Margaret Isioma Ojeahere

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Mental Health Literacy, Language,
and Communication. The Case for
Vaccination Refusal
With the syndemic threat of Covid-19 still present, several ques-
tions remain unanswered. Lessons learned by experts and political
authorities may be of great importance for future outbreaks of dis-
eases, ecological challenges due to exhaustion of natural resources
and climate change, natural catastrophes, and war.
One of the characteristics of historical epidemics and disasters
has been the fall of prestige and credibility of institutions, religious
and secular. The cognitive abilities of citizens are crucial when con-
certed action is demanded from individuals and populations. Dis-
cerning what is true and what is false in scientific or political dis-
courses is not easy, especially if sources of information are diverse
andproofofintellectualsolvencyisnotalwaysathand.Thechallenge
is to increase health literacy, particularly in aspects involving behav-
ioral change and prevention of harm.
One of the most challenging tasks is risk communication. Risk is
the probability of harm and depends on severity of potential harm
and probability of occurrence. Usually expressed in statistical terms,
these are difficult to understand; sometimes, they seem too abstract
or remote. In addition, the acceptance of appropriate measures pro-
posed by scientists and authorities demands trust and confidence.
Asobservedinmanycountries,peoplereacttoimpositionsinwidely
different forms hampering prevention and risk management1
.
This is the case when reactions to vaccination against infectious
diseases are examined. In several countries and populations, resis-
tance and opposition have been observed. What experts consider a
rational response is not always present. It may be due to several caus-
es that need to be elucidated in the context of mental health literacy
and risk communication.
An important contribution comes from critical discourse anal-
ysis2
. Examining argumentative strategies and comparing them with
actual behavior may shed light on the reasons for refusing vaccina-
tion and reluctance to confinement and physical distancing. During
the pandemic, several metaphoric fields were opened and entered
common language. People heard about “waves” of infection, “war”
against viruses, “new normality”
, “lockdown” and “social distance”
.
These metaphors find their place in everyday language, permeate
cultural habits, and induce responses. The problem is that their com-
prehension may differ widely from group to group and are translated
with shades of meaning difficult to deal with.
Risk management and communication in times of widespread
mistrustandthreatemphasizetheneedtorealizethatscientificknowl-
edge, as in fact all knowledge, is participation. To know is to take part
in a web of facts, assumptions, and anticipations. This ideal is ham-
pered when language games employed by persons differ in depth and
breadth. The critical point here is translation. Translation sciences
come to the foreground. Experts and political leaders need to convey
their messages considering the denotations and connotations of terms
and considering the emotional significance of discourses.
The loss of credibility in science and political leadership may
lead to negation of evidence and obstruction of appropriate mea-
sures. In the case of vaccination, for instance, opposition came from
people who asserted their right to take autonomous decisions, de-
spite adverse consequences. This empirical autonomy is confused
with liberty to act against qualified advice and renews the dangers
of paternalism, which is beneficence without autonomy. In addition,
to enforce measures may be interpreted as totalitarian imposition of
socialrules.Infact,restrictionsforthesakeofhealthmayderivefrom
political domination.
Another source of opposition to vaccination and non-pharma-
cological measures derives from the potential economic gains that
pharmaceutical companies or powerful countries may have. Even if
measuresforpreventionaresupportedbyfactsandresults,thecoun-
terargument comes close to conspiracy theories which assume that
both the infection and its control are stratagems for controlling peo-
ples and communities.
The road to health literacy is difficult but necessary. Adequacy
of measures and proportionality of response demanded from people
must be permanently assessed. Social intelligence depends on fair
appraisal of dangers and harms and on “cultural fairness” on the part
of professionals and policymakers3
.
REFERENCES
1. 1. Lolas, F. Postpandemic psychiatry: The adequacy challenge
GMHP Review (Washington, DC) 3(2):6, 2022.
2. 2.Kotatkova,A.,Salvador,V.Pragmaticadelstextosidebatsocial
sobre la Covid-19: estrategies negationistes, liberalisme i comu-
nitarisme. (Text pragmatics and social debate about Covid-19:
negationist strategies, liberalism, and communitarism). Cultura,
Lenguaje y Representación XXVII:57-74, 2022. doi: http://dx.doi.
org/10.635/clr6535
3. 3. Lolas, F. Behavioral vaccinology. GMHPReview (Washington
DC) 3(1):6, 2022
Fernando Lolas, MD, IDFAPA1
1
University of Chile and
Central University of Chile,
Santiago, Chile
Fernando Lolas

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Victor Pereira-Sanchez, MD, PhD1-3
İdil Kına, MD3,4
1
Department of Child and Adolescent Psychiatry, NYU Grossman
School of Medicine, New York, NY
2
Department of Psychiatry, Amoud University, Borama, Somaliland
3
World Network of Psychiatric Trainees
4
Ege University Faculty of Medicine, Bornova/İzmir, Turkey
Understanding and Improving
Global Education in HumanRightsin
PsychiatricTraining:TheWorldNetwork
of Psychiatric Trainees Initiative
Victor Pereira-Sanchez İdil Kına
Psychiatry as a discipline, and its professionals, have histori-
cally had a multifaceted relationship with human rights1
. We have
come a long way in making the rights and dignity of people with
mental disorders a priority of mental health care, yet structural
inequalities that lead to mental health struggles and jeopardize
access to care, further marginalization and victimization of peo-
ple with mental health struggles2
, and political abuse of our field3
are living challenges. Globalization has exposed the shame of
current, widespread deficits in our profession as well as heinous
violations of human rights of large populations across the world,
and at the same time has also provided an opportunity for col-
laborative efforts to address those challenges. Hence, educating
current and prospective psychiatric trainees on the historic and
current intersections of human rights and psychiatry is not just
relevant but urgent.
In June 2022 at the World Network of Psychiatric Trainees
(WNPT)4
we launched an initiative to understand the current
state of education in this topic in psychiatric training programs
worldwide and to initiate actions to address deficiencies and im-
prove psychiatric education. We started with a pilot survey for
WNPT members and other colleagues at various training and
professional stages, which was conducted in the same month. We
obtained a geographically diverse participation, with 78 respon-
dents from 32 countries across all continents, most of which came
from low and middle income nations. We explored the education-
al exposure of participants to topics related to human rights in
mental health and psychiatry, as well as their interests, views, and
suggestions. We ended up with a balanced distribution of gen-
der, and about half of respondents were early career psychiatrists,
with substantial proportions of trainees and senior psychiatrists.
Most respondents reported a medium to high familiarity with
the topic and a high interest in it. Interestingly, most participants
reported that human rights were not explicitly included in their
psychiatry training programs, and many of them had to learn
on their own outside of those programs. Conversely, almost all
participants agreed that human rights education should be man-
datory. Among the areas and topics they had been educated in,
the predominant were coercion and involuntary treatments, stig-
ma and discrimination, access to healthcare, and ethics, whereas
most respondents showed interest in other topics to be covered in
the future, including the rights of minority groups, cultural com-
petence and humility, advocacy, policymaking, and disparities in
healthcare. In terms of teaching methods, a large proportion of
respondents said that they relied mostly on clinical experiences
and didactic lectures for trainees, but they expressed interest in
diversifying more the methods in future efforts, including as well
events with people with lived experience. We finally asked par-
ticipants to point at potential and actual benefits and risks of ed-
ucation in human rights; most of them agreed on many benefits,
including improved decision making, self-awareness, leadership,
better therapeutic relationship, and improving access to mental
health care and the social perception of psychiatry; and where-
as many participants identified no risks, significant proportions
feared that these education efforts could be too broad and futile,
and there are risks of overburdening the workload, losing focus
on clinical practice, blurring lines between psychopathology and
social issues, and risking clinician’s impartiality falling into parti-
san activism.
Beyond our survey, as we look at scientific literature, it seems
that current education in human rights, while not necessarily
explicit and consistently provided, flows through different, over-
lapping educational frameworks. In core psychiatry training pro-
grams, a number of methods are used to provide practical and
experiential knowledge, and issues of human rights are often pres-

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Psychiatric Trainees (WNPT)
is a group connecting psy-
chiatrists in training all over
the world - colleagues inter-
ested in learning more about
it and trainees interested in
joining can visit our website
worldtrainees.org.
REFERENCES
1. Jařab J. Psychiatry and human rights: a difficult relationship,
butwithagrowingpotential.Neuropsychiatr.2015;29(3):106-
111. doi:10.1007/s40211-015-0157-7
2. Drew N, Funk M, Tang S, et al. Human rights violations of
people with mental and psychosocial disabilities: an un-
resolved global crisis. Lancet. 2011;378(9803):1664-1675.
doi:10.1016/S0140-6736(11)61458-X
3. Jay M, Mahdanian AA, Tavakoli E, Puras D. Political
abuse of Iranian psychiatry and psychiatric services. The
Lancet. 2022;400(10367):1923-1924. doi:10.1016/S0140-
6736(22)02183-3
4. Pereira-Sanchez V, Virani S. The World Network of Psychi-
atric Trainees: A Global Home of Psychiatry Residents and
Fellows. IACAPAP Bulletin. 2021;December 2021(64). Ac-
cessed December 22, 2021. https://iacapap.org/the-world-
network-of-psychiatric-trainees-a-global-home-of-psychia-
try-residents-and-fellow/
5. The Yale University Department of Psychiatry Social Justice
and Health Equity Curriculum. Accessed June 22, 2022. https://
medicine.yale.edu/psychiatry/education/social/justice/
6. Puras D, Gooding P. Mental health and human rights
in the 21st century. World Psychiatry. 2019;18(1):42-43.
doi:10.1002/wps.20599
7. United Nations. Convention on the Rights of Persons with
Disabilities (CRPD) | United Nations Enable. Published
December 13, 2006. Accessed June 20, 2022. https://www.
un.org/development/desa/disabilities/convention-on-the-
rights-of-persons-with-disabilities.html
8. Glover-Thomas N, Chima SC. A legal “right” to mental health
care? Impediments to a global vision of mental health care
access. Nigerian Journal of Clinical Practice. 2015;18(7):8.
doi:10.4103/1119-3077.170822
9. Vance MC, Kennedy KG. Developing an Advocacy Curricu-
lum: Lessons Learned from a National Survey of Psychiatric
Residency Programs. Acad Psychiatry. 2020;44(3):283-288.
doi:10.1007/s40596-020-01179-z
10. Every-Palmer S, Kininmonth L, Newton-Howes G, Gordon
S. Applying Human Rights and Reducing Coercion in Psy-
chiatry following Service User-Led Education: A Qualitative
Study. Health Hum Rights. 2021;23(2):239-251.
11. Pereira-Sanchez V, Gürcan A, Gnanavel S, et al. Violence
Against Psychiatric Trainees: Findings of a European Survey.
Acad Psychiatry. 2022;46(2):233-237. doi:10.1007/s40596-
021-01539-3
12. World Health Organization. QualityRights materials for
training, guidance and transformation. Published Novem-
ber 12, 2019. Accessed June 22, 2022. https://www.who.
int/publications-detail-redirect/who-qualityrights-guid-
ance-and-training-tools
ent in areas such as cultural competency and humility, structural
competency, management of agitation, ethics, legal and forensics,
and others. On the other hand, some training programs offer
specific training tracks with curricula related to human rights5
.
Trainees can also electively gain more education through re-
search projects and extracurricular activities, especially through
international collaboration. Among the areas of interest to cover
in education on human rights, involuntary treatments and coer-
cion in psychiatry remains a fundamental topic for further discus-
sion and progress6
, making the United Nations Convention of the
Rights of Persons with Disabilities, CRPD7
, with its lack of global
enforcement and the controversies it has elicited, ever relevant
for psychiatric trainee’s education. Along with this topic, often
dominant in discussions on human rights in psychiatry, access to
healthcare8
, disparities, the rights of minority groups, and advo-
cacy skills9
are topics that require further attention.
Barriers to advance education in human rights in psychiatry
training seem to be mainly structural and cultural. Among the
structural, the lack of training models, confusion and controver-
sies surrounding legislation, workplace and infrastructure lim-
itations and hierarchies10
, and actual violence against psychiatric
trainees11
seem to be prominent. Among the cultural, ‘paradigm
collisions’10
among generations, stakeholders, and ideologies
make it difficult to reach constructive consensus to advance the
field; additionally, it is important to note that education efforts
in human rights in psychiatry worldwide should balance the
respect for fundamental rights with the respect for legitimate
divergences in culture, avoiding the imposition of new forms of
cultural colonialism.
Future directions include: (1) systematic research on the state
of the art, investigating as well cross-cultural, nations, and demo-
graphic variability; (2) taking advantage of existing educational
frameworks to inform them with human rights discussions and
reflections; (3) advancing efforts in the development of curricu-
lum explicitly covering human rights, with involvement of train-
ees and people with lived experience and informed by internation-
al policy and cultural considerations; (3) promoting international,
enforceable and evaluable training standards based on such cur-
riculum; and (4) promoting extracurricular opportunities such as
the World Health Organization QualityRights online toolkit12
to
empower trainees to become drivers and leaders of change.
Respect for human rights in psychiatry and mental health is
a fundamental aspect of the psychiatric profession, yet it seems
an educational area poorly covered in psychiatric training pro-
grams across the world. A human rights curriculum should be
developed, taking advantage of existing educational frameworks,
and providing trainees with awareness, knowledge, and skills (in-
cluding advocacy). Our pilot work suggests that trainees are eager
to learn this, and WNPT, seeking to partner with allied organiza-
tions, is leading an effort towards understanding and addressing
these training needs across the world.
*Notes: The contents of this article are partially based on an
oral virtual presentation by Dr. Pereira-Sanchez at a symposium
during the 22nd World Congress of Psychiatry by the World Psy-
chiatric Association (WPA) in August 2022. The World Network of

ASIA/PACIFIC
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Roy Abraham Kallivayalil, MD1-3
1
Professor and Head, Department of
Psychiatry, Pushpagiri Institute of
Medical Sciences and Research Centre,
Thiruvalla, Kerala- 689101, India
2
Vice President (Asia Pacific), World
Federation for Mental Health
3
President, World Association of
Social Psychiatry (2016-2019)
Roy Abraham Kallivayalil
Access to Care in South India -
Reaching the Unreached
Access to care is one of the major constraints to delivering
mental health care in the Low and Middle Income (LAMI)
countries. This is especially so in a huge country like India with a
massive population of 1.4 billion. Lack of infrastructure, paucity
of psychiatrists and other mental health professionals, widely
prevalent stigma and poor investment in mental health all leads
to poor access. The number of psychiatrists in India is just
over 6,000. Thus, on an average one psychiatrist has to cover a
population of about 230,000 which is almost an impossible task.
Delivery of mental health care though primary care has had
only limited success as the primary care physicians are already
overburdened with general medical care. Hence, they are able
to set apart only very limited time and effort for mental care
delivery.
It is in this context, we have formulated an entirely new
approach - delivering mental health care through NGOs (Non-
Governmental Organisations) and lay counsellors who are
trained by us. We have chosen to work with an NGO named
Mariasadanam in Pala, Kottayam District, Kerala, India. We
started the programme in 2011 and it has now become an
innovative project. Our research “Effectiveness of a new low-cost
psychosocial rehabilitative model to reduce burden of disease
among persons with severe mental illness” was published in
2018. We have been continuing the programme effectively for the
last 11 years. The Pushpagiri Psychiatry team makes a monthly
visit here for guiding treatment and rehabilitation. Currently
more than 400 persons are housed in this rehabilitation centre,
where they are trained in various vocations like tailoring, candle
making, carpentry, painting, basket making etc. Besides, the
inmates have formed music and drama troupes which are staged
in many places in the State. In December 2022 and January 2023,
we have organised training programmes on “access to mental
health care” for lay counsellors and volunteers. This has received
wide spread acclaim.
Photo caption: Mariasadan Rehab Centre Pala Kottayam, India
Jan 2023: Training program on Access to Care: Inaugural address
by Prof Roy Kallivayalil and later he honoured Mr Ramesh
who had recovered from mental illness. Also seen are Santhosh
Joseph (Centre Director), Dr Asha Maria Davis, film actor Chaly
Pala and Fr Ritto Matthew. [The author of this manuscript has
provided these pictures to Global Mental Health & Psychiatry
Review editors and has given permission to publish them].
REFERENCES
1. Kallivayalil RA, Sudhakar S. Effectiveness of a new low-
cost psychosocial rehabilitative model to reduce burden
of disease among persons with severe mental illness:
An interventional follow-up study. Indian J Psychiatry
2018;60:65-70.
2. Kallivayalil RA,Enara A. Mental health in an unequal world
- The role of social determinants. Indian J Soc Psychiatry
2022;38:3-6.

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Yueqin Huang, MD, MPH, PhD1
1
Peking University Sixth Hospital,
Peking University Institute of Mental
Health, Beijing 100191, China
Yueqin Huang
Health Service Utilization in
Patients With Mood Disorder in
ChineseAdults
Objectives
To describe the status of health service utilization in Chinese
adults with mood disorder in order to explore related factors.
Methods
The China Mental Health Survey was carried out
nationwide. Patients with mood disorders in Chinese adults were
investigated about visiting outpatient service rate, admission
rate, treatment rate in general hospitals, and treatment rate
in psychiatric hospitals. Using multiple linear regression and
logistic regression for complex sampling data, demographic and
related factors of the patients with mood disorder and health
service utilization were analyzed.
Results
For the patients with mood disorders, the rate of visiting
outpatient service was 37.94%, the admission rate was 21.03%,
and the treatment rate in psychiatric hospitals was 26.85%.
Patients with mood disorders most often sought help from non-
psychiatric medical professional, went to general hospitals, and
received prescribed medication. Comorbid physical diseases
and older age were risk factors of hindering health service
utilization in patients with mood disorders
Conclusions
Adult Chinese Patients with mood disorders are less likely
to seek psychiatric services, but are more likely to visit general
hospitals because of comorbidity with physical diseases.
REFERENCES
1. LuJ,XuX,HuangY,etal.Prevalenceofdepressivedisorders
and treatment in China: a cross-sectional epidemiological
study. The Lancet Psychiatry, 2021, 8(11): 981-90.
2. Huang, Yueqin, et al. Prevalence of mental disorders in
China: a cross-sectional epidemiological study. The Lancet
Psychiatry, 2019; 6(3): 211-224.
3. Lee S, Tsang A, Huang Y, et al. Individual and societal
impact on earnings associated with serious mental illness
in metropolitan China. Psychiatry research, 2009, 180(2):
132-6.
4. Wang P S, Lane M, Olfson M, et al. Twelve-Month Use of
Mental Health Services in the United States: Results From
the National Comorbidity Survey Replication. Archives of
general psychiatry, 2005, 62(6): 629-40.

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Interviewwith
Professor Dr. Danius Puras
Ruta Karaliuniene MD1
1
Clinic for Psychiatry and
Psychotherapy, Elblandklinikum
Radebeul, Radebeul, Germany
Ruta Karaliuniene
Danius Puras
(Dr. Karaliuniene) Dear Prof. Puras, you have been a role
model for our post-soviet generation. I remember your lec-
tures as a medical student, where you presented various prob-
lems and perspectives in psychiatry. Considering post-soviet
countries, how did psychiatry change during these 30 years?
(Dr. Puras) First of all, thank you for your interest in my work.
To start with, I have to say that the Eastern and Central European
region is still in a prolonged transition; of course, in 30 years, we
achieved some progress, but I should say more on the surface. For
example, conditions in mental health facilities improved dramati-
cally. I still remember those frightening living and treatment con-
ditions in psychiatric care and extended care institutions, such
as insulin coma therapy. The idea behind this was that if some-
one was diagnosed with schizophrenia, all methods were better
than doing nothing. This experience has contributed to loading
myself for change. But the changes were only possible after the
1990s when Lithuania gained its independence. Nowadays, psy-
chopharmacological treatment has improved significantly, but
structural problems, like many patients in long-term institutions,
are still there. Nowadays, we count on the biopsychosocial mod-
el in modern psychiatry in our region, but the biological aspect
still plays a crucial role in treating patients. The main reason for
this development was the dominance of psychopharmacological
treatment. With a lack of psychotherapy use, the patients have
been treated mainly with medication for years. Even though I am
proud that my country progressed so much economically and so-
cially, psychiatry was unable to make the same progress.
You pay a lot of attention to community psychiatry in your ar-
ticles and publications. Great examples are your initiatives like
establishingtheAssociationforpeoplewithdisabilities,“Hope,”
and the Child Development Centre in Vilnius, Lithuania, years
ago. How did society react to these innovations back then?
The time was very exceptional 30 years ago. Almost every-
one welcomed change; we were united, wanted to stay indepen-
dent, and were looking for ways to improve our people’s lives.
The feeling was that everything was in our hands, there was no
bureaucracy, and we did many things based on trust and belief
for the better. So, I just came up with my idea for the Ministry
of Health, and we agreed that establishing a center for children
with disabilities should take place. Soon we recognized we had
no building for that, but the building was quickly found. It was an
old communist building with 20 flats, mothers and children were
living and cooking in the kitchen, and we started to teach the staff
the possible non-pharmacological interventions. Because before
then, children with autism were treated like the ones with schizo-
phrenia and with medication only. We also had guests from the
United States, who were very surprised and said they do not have
such a center in the USA. Unfortunately, bureaucratic processes
took place, and they started questioning: “could children with dis-
abilities cook by themselves”…
Your voice in the international psychiatric society became
even more heard as you were elected to the United Nations
Committee on the Rights of the Child in 2007 and appointed
as UN Special Rapporteur on the rights to physical and men-
tal health in 2014. What regions still have the most consider-
able pending work considering human rights and psychiatry?
My mandate was global; I was able to travel a lot and see dif-
ferent world regions. My task was to look for everyday challenges.
Even though there are some regional peculiarities, the common
issues, including very well economically developed countries,
were issues with human rights. For example, the level of psychia-
try services in Africa is deficient, and where mentally ill may even
be trapped and chained at home. While in Global North, there
was too much expectation from the biomedical approach. Giving
too much hope for pharmacological treatment where there was a
longing to reduce stigma in this way. Unfortunately, the reduction
of coercion was not seen as expected. The thing that came to my
mind is that we are having a global human rights crisis. And we
cannot improve mental health without enhancing human rights.

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I remember a meeting in Trieste [Italy] where I was talking about
my report. During the conference, country representatives from
South Korea, Iceland, Japan, and Poland approached me, wonder-
ing how I knew their countries’ situation so well. The thing was
that the problems were the same, even though the nations were
highly different. This situation was a great example and a consid-
erable reward for my work internationally.
Human rights, not only in psychiatry but also in different
areas, are gaining a lot of attention worldwide. Considering
this, what are the most significant difficulties human rights
still face in our modern world?
The current war in Europe also raises concerns about human
rights violations. Three days ago, I was in Norway, one of the
world’s most developed countries, considering human rights.
Even there, many people are not satisfied with the mental health
system. Nowadays, experts are discussing whether there are bet-
ter opportunities for change for human rights in the Global North
or the Global South, and it seems that the challenges are still uni-
versal. Another significant issue is domestic violence in the family
environment, especially in countries where xenophobic beliefs
tend to be interpreted as traditional. Cultural things are essential,
but unfortunately, they can often become harmful practices.
Our region, Eastern Europe, is marked by decades of socialism.
Xenophobic ideas, as well as discrimination on any ground, in-
cluding gender or sexual orientation, have a long history in our
society. There are some excellent initiatives, but there is still a long
way to go — any violence imposed by totalitarian regimes also
harms mental health significantly. There are two types of human
rights: economic-social and civil-political. All totalitarian regimes
tend to destroy human connections and diversity. For example,
after the Olympic Games in Moscow in the 1980s, there were no
Paralympic Games. The organizer stated that there were no peo-
ple with any disabilities in the Soviet Union. When those people
were hidden from society, there was no chance to maintain a tol-
erance for diversity.
After completing your appointment as a Special Rapporteur,
you continued your non-governmental work as a director of
Lithuania’s human rights monitoring institute. What experi-
ences are the most rewarding? What are the biggest challeng-
es of your work now?
Mental health and the rights of refugees and migrants are one of
the several priorities of our work at the institute. For example,
we actively monitored the crisis in 2021, where more than 5000
people crossed the border between Belarus and Lithuania. To
some extent, these people were encouraged to cross the border,
expecting they could immediately enter the European Union this
way. But these are the people fleeing from challenging regions like
Iraq and Syria. The public perceived them as dangerous because
of the lack of information. In my previous reports, I stretched the
harm to mental health and human rights of xenophobic reporters
of world political leaders
during an earlier refugee
crisis. We continue to
raise this issue for people
to understand and avoid
any discrimination on an
institutional level. For ex-
ample, last year, we dedi-
cated Mental Health Day
to the children in refugee
camps. Of course, there
have been some reactions
from people who were not satisfied with this decision, stating that
we need to take care of local children first. But the main point we
want to address is that all children living in the territory of Lith-
uania are the children of Lithuania. And they have equal rights.
You have managed to synchronize your clinical, social and ac-
ademic work during your career. What would be your advice
to early career psychiatrists aiming to follow your path?
I think that a doctor should be a good clinician first. But also,
the psychiatrist must always follow and understand the global
context. As a young psychiatrist, I had some experiences which
I will never forget. For example, some senior colleagues used to
diagnose punks with schizophrenia only because of their appear-
ance. As those patients refused to talk with a psychiatrist, this
was interpreted as catatonia. Now it sounds ridiculous, but this
was during my psychiatry training. Also, I remember how my su-
pervisor advised the husband of my patient, who had psychosis
– he wanted him to divorce the patient as soon as possible. In my
opinion, this was not according to patient interests. We as doctors
should always consider what is best for the patient first and not
for the others. I believe human rights are the key to good mental
health services1-2
.
Dear Professor Puras, thank you for the interesting conversa-
tion as well as for your many years of WHO service promoting
and protecting human rights.
This interview took place during the ‘Rethinking Mental Health
Conference’, September 7th
2022 in Vilnius, Lithuania
REFERENCES
1. Final report of the Special Rapporteur on the right of every-
one to the enjoyment of the highest attainable standard of
physical and mental health, Dainius Pūras. Retrieved from:
https://www.ohchr.org/en/documents/thematic-reports/
a75163-final-report-special-rapporteur-right-everyone-en-
joyment-highest
2. Report of the Special Rapporteur on the Right of Everyone to
the Enjoyment of the Highest Attainable Standard of Physical
and Mental Health, Dainius Pūras. Retrieved from: https://
digitallibrary.un.org/record/798710

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Migration Healthcare
– Current Insights
from Switzerland
Fabian Herbert Kraxner, MD1
1
Department of Psychiatry and
Psychotherapy, Hospital of
Affoltern, Zürich, Switzerland
Fabian Herbert Kraxner
Over the last months, around 122,000 people are undergo-
ing the asylum process in Switzerland. We currently face the
largest refugee movement since the 2nd World War1
.
So what does working with refugees in Switzerland look like?
The prime challenge in migration health is the question of
how to reach them. Forced migrants, asylum seekers, and re-
fugees, manipulated or influenced by their direct and indirect
experiences, are a very vulnerable part of the population. Hence,
building trust, a key factor to convince them about the impor-
tance of early testing, screening, and diagnosing, is crucial for
the success of migration health. For this, maintaining a close
relationship and extensive network is a means to reach out and
approach this vulnerable population.
Working with refugees is very inspiring. Personally, I am
moved by their daunting migration journeys. When dealing
with their stories and its impact on their health, particularly
their mental health, the strength and resilience of each person
becomes evident.
As Switzerland is one of the most attractive destinations for
migrants and refugees, it hosts a great diversity of immigrants
from around the globe. Overall, Switzerland wants to improve
health care for refugees. One way to do that is by improving
health screening of migrant populations upon their arrival. We
also aim to facilitate the work of family doctors as they frequent-
ly come into contact with refugees in Switzerland. Moreover,
migrant and refugee health is a topic increasingly important for
healthcare professionals of all levels not only in Switzerland, but
around the world.
Asignificantproportionofasylumseekersandrefugeeslivingin
Switzerland face confronted mental health challenges and trauma-
tization2
. However, the mentally ill who require highly specialized
psychiatric interventions constitute a minority. For the majority of
mentally distressed asylum seekers and refugees the need is pri-
marily to receive support that strengthens their resources and helps
them deal with psychosocial stress. In this regard, psychosocial in-
terventions should be organized in such a way that they are tailored
in a stepwise manner to address the different needs of asylum seek-
ers and refugees at an appropriate level of intensity/specialization3
.
In Switzerland, and everywhere, everyone has the right to
good healthcare4
.
REFERENCES
1. Staatssekretariat für Migration SEM, Asylstatistik To-
tal Stand ZEMIS vom 30.11.2022
2. Mueller, J.; Schmidt, M.; Staeheli, A.; Maier, T. (2011):
Mental health of failed asylum seekers as compared with
pending and temporarily accepted asylum seekers. Eur. J.
Public Health, 63 21, S. 184–189
3. Inter-Agency Standing Committee (IASC, 2017): A Com-
mon Monitoring and Evaluation Framework for Mental
Health and Psychosocial Support in Emergency Settings.
4. Swiss confederation, Federal Office of Public Health FOPH,
The Federal Council’s health policy strategy 2020–2030

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Ifyouaredealingwithglobalhealthandmentalhealth,ifyouare
working in social and cultural psychiatry, if you are doing research
on the environment, climate change and eco-social anxiety, or if you
are coping with the impact of the COVID-19 pandemic/syndemic
that is becoming endemic – you cannot afford not to read this book.
Whetheryouendorseitwholeheartedly,disagreewithitvehemently,
or fall somewhere in between, this is a veritable compendium of all
the cutting-edge ideas and progressive movements out there in the
21st
century, voiced by the people who lead those movements.
Pluriverse: A Post-Development Dictionary is a thematic
dictionary that contains more than one hundred essays on
“transformativeinitiativesandalternativestothecurrentlydominant
processes of globalized development, including its structural roots
in modernity, capitalism, state domination, and masculinist values”
(back cover). This volume catalogues a series of “critical essays on
mainstream solutions that ‘greenwash’ development,” offering
instead “radically different worldviews and practices from around
the world that point to an ecologically wise and socially just world”
(back cover).
The editors are activists with a global reach: Ashish Kothari is in
India and coeditor of Alternative Futures: India Unshackled; Ariel
Salleh is an Australian scholar-activist and author of Ecofeminism
as Politics and editor of Eco-Sufficiency and Global Justice; Arturo
Escobar teaches at the University of North Carolina and author of
Encountering Development; Federico Demaria is with Autonomous
University of Barcelona and is coeditor of Degrowth: A Vocabulary
for a New Era; and Alberto Acosta is an Ecuadorian economist,
activist, and former president of the Constituent Assembly of
Ecuador.
A Radical Critique of Development
The entire volume turns on one word: development – and its
vicissitudes.
The very first line in this book is, “The idea of development
stands like a ruin in the intellectual landscape,” written in the
Foreword by Wolfgang Sachs (1992), citing his own Development
Dictionary written 25 years earlier. They had naively proclaimed
“the end of the development era,” only to see it survive in a “political
coma” lasting decades.
This is the antidote – a post-development dictionary.
“This dictionary turns to examine the limits of
developmentalism as it shapes reformist solutions to global
crises” (Introduction, p. xxiv). “[T]he great 20th
century political
models – liberal representative democracy and state socialism –
have become incoherent and dysfunctional forms of governance,
even if achieving welfare and rights for a few” (p. xxiv), the editors
affirm, invoking a prescient notion from Italian political theorist
Antonio Gramsci (1971/1930, pp. 275-76), writing from a Fascist
prison: “[T]he crisis consists precisely in the fact that the old is
dying and the new cannot be born; in this interregnum a great
variety of morbid symptoms appear.”
“‘Development’ is a plastic word, an empty term with
positive signification” (p. xiii). In his brilliant essay, Uwe Poerksen
(1995) describes plastic words as “context-autonomous” words
that “superficially resemble the terms of science, but lack the
Vincenzo Di Nicola, MPhil, MD,
PhD, FRCPC, FCAHS, DLFAPA,
DFCPA
Professor of Psychiatry, University
of Montreal & The George
Washington University
Founder & President, Canadian
Association of Social Psychiatry
President, World Association of
Social Psychiatry
Vincenzo Di Nicola
Developmentand ItsVicissitudes – A Reviewof
Pluriverse: A Post-Development Dictionary
[Editors: Ashish Kothari, Ariel Salleh, Arturo Escobar,
Federico Demaria, & AlbertoAcosta]
BOOK REVIEW

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precisely defined meanings of such terms, and their freedom
from associations.” Using the same word in scientific discourse
and beyond it creates confusion and conflation, leading to the
“assumption of kinship.” In common usage, “these nephews of
science become stereotypes.” Pretending to be anchored in science
and facts (the current buzzword is “evidence-based”), plastic words
like development are so easyily integrated in our society that they
become “commonsense, background concepts in our thinking.”
(See http://kuny.ca/blogs/2010/52/essays/characteristics-of-plastic-
words/.)
Empty, plastic and pliable, insidious and invasive, but with
multiple implied meanings, “development” continues its “status as
a perspective” since it is deployed in an international network from
the UN to NGOs (p. xiii).
Against the pervasive emptiness of development, the authors
offer their concrete pluriverse:
“The notion of the pluriverse questions the very concept of a
universalitythatiscentraltoEuropeanmodernity.Withtheirphrase
‘A world where many worlds fit’
, the Zapatistas give us the most
succinct and apt definition of the pluriverse” (p. xxxiii). Against
universality, they offer us a “compendium of alternatives reaches for
integrative and inclusive practices” (p. xxxiii).
A Closer Look
The volume is divided into three sections:
I Development and Its Crises: Global Experiences
“The ‘development’ concept, already a few decades old, needs
to be reassessed as a matter of political urgency” (p. xviii). The six
essays span all the continents, addressing development and its
“relation to the multiple crises of modernity” (p. xviii).
The most informative essay for a newcomer, “The Development
Project” by Philip McMichael (USA), outlines a history of how
development has been deployed economically and politically.
But for me the most provocative and productive essay is on
“Maldevelopment” by José María Tortosa (Spain). Rejecting the
contrived classification of US President Truman’s famous proposal
of developed nations coming to the aid of underdeveloped ones,
Tortosa concludes that “all countries are … maldeveloped and the
ultimatereasonistheirimmersionintheworldsystemthatproduces
… capitalism, which is where the problem seems to reside” (p. 11).
II Universalizing the Earth: Reformist Solutions
This section is sharply critical of the innovations arising in the
Global North, promoted as “progressive ‘crisis solutions’
,” exposing
their internal inconsistencies as “ecologically wasteful profit-
making distractions” (p. xix). These essays on reformist solutions
are the most likely to provoke the woke progressive crowd who are
committed to constant adaptations in order not to change. This
idea was coined in a celebrated Italian novel, The Leopard (1958) by
Giuseppe Tomasi di Lampedusa (himself the last in a line of minor
Sicilian princes), in which the nephew of an aging prince informs
his uncle facing challenges to his upper class privileges and tradition
that,“Inorderforthingstostaythesame,thingswillhavetochange.”
Among the ideas eviscerated here – because they ultimately
aim to preserve privilege – are: “Development Aid,” described as
“concerted strategic efforts
among western industrial
powers to sustain [their]
economic and political
privileges” (Jeremy Gould,
Finland/Zambia) and
“Ecomodernism” which sees
salvation in technology (Sam
Bliss, USA; Giorgos Kallis,
Spain). Other essays attack
such sacred cows as “Efficiency,” “Lifeboat Ethics,” “Reproductive
Engineering,” “Smart Cities,” “Sustainable Development,” and
“Transhumanism.” Reader, brace yourself.
III A People’s Pluriverse: Transformative Initiatives
This is the heart of the volume, a veritable compendium of
integrative and inclusive practices, reflecting “worldviews and
practices, old and new, local and global, emerging from indigenous,
peasant and pastoral communities, urban neighbourhoods,
environmental, feminist, and spiritual movements” (p. xix).
A Personal Selection: “Take Your Time”
There are three key forebears of this multifaceted dictionary:
Ivan Illich (1973), The Club of Rome (Meadows, et al., 1972), and
Thomas Robert Malthus (1803). My personal selection of three
key entries reflects their influence throughout the pluriverse of this
volume.
“Conviviality” – David Barkin (Mexico)
Ivan Illich (1926-2002) was the spiritual mentor of Sachs’
Development Dictionary (1992) and remains an abiding presence
in this one. His Tools for Conviviality (1973) introduced the term
conviviality, defining it as “individual freedom realized in personal
interdependence and, as such, an intrinsic ethical value.” A convivial
society would be “a modern society of responsibly limited tools.”
In his essay on “Conviviality” Barkin sees it as a “platform for the
forgingofanewsociety”(p.136)that,asIllichwrote,“transcendsthe
profound limitations of the present world” substituting “convivial
for industrial tools” predicated on “socialist justice” (Illich, 1973,
p. 12). Barkin perceives that today’s conditions make it far more
likely for conviviality to emerge: “No longer fooled by the promises
of a prosperous future of perpetual growth, myriad alternatives are
sprouting in the search for alternatives” (p. 138). Many of them are
documented in this volume.
“Eco-Anarchism” – Ted Trainor (Australia)
Inthisessay,Trainorstarklysetsoutthestakesforeco-anarchism:
“[I]n striving endlessly for growth and affluence [development]
inevitably creates and accelerates ecological destruction, inequality
and poverty, social breakdown, and armed conflict over resources
and markets” (pp. 160-61). In making the case for “limits to growth,”
he invokes The Club of Rome (Meadows, et al., 1972) to replace
development with The Simpler Way vision. Trainor argues for
“small-scale settlements … self-sufficient and self-governing …
driven by a culture of simplicity, frugality, and non-material sources
of life satisfaction” (p. 161). These settlements, he asserts, must be

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eco-anarchist since “only participatory self-governing communities
can run small-scale economies well” (p. 161).
“Slow Movement” – Michelle Boulous Walker (Australia)
This essay places the solution to the vicissitudes of development
squarely on slow activism. The roots of this are with the Slow Food
Movement in Rome, a protest against an American fast-food outlet.
ItmorphedintoalargerSlowMovementthatnowrangesfromSlow
Cities to Slow Thought (Di Nicola, 2018). “Slow activism calls for a
decelerationofthepace ofmoderntechnologicallife”…“dominated
by a logic that equates speed with efficiency” (p. 305). Key words
are contemplation and artful slowness. The admonition of my Slow
Thought Manifesto is “Take your time” (Di Nicola, 2018). With its
roots in the Slow Food protest, the Slow Movement harkens back
to the seminal ideas of Thomas Robert Malthus (1766-1834) who
identified the conundrum that while increased food production
leads to improved well-being, such abundance leads to population
growth, creating the “Malthusian trap.” Malthus (1803, p. 13)
predicated that “The power of population is indefinitely greater
than the power in the earth to produce subsistence for man.”
Technological innovations in agriculture have rescued us out of this
trap but it has come at a huge ecological price that is unsustainable
for the planet.
Many such readings are possible. I invite you to make your own!
Conclusion: A Book You Need
In conclusion, this is a book that creates its own necessity. From
economics and international relations to child psychology and
psychiatry (Di Nicola, 1992), “development” is a firmly entrenched
plastic word that entered the popular imagination although
its apparent significance belies its fundamental emptiness and
destructiveness. Armed with critiques and possibilities, this volume
helps us reach for alternatives that are integrative and inclusive.
While development reflects the dominance of the Global North, it is
theGlobalSouththatbearstheburdenandpaystheprice(DiNicola,
2020). Yet, the good news is that the Global South is also now the
generator of alternative slow, small-scale, pluralistic practices that
point the way through our global crises.
Like its radical critique of development which creates binary
categories(“developed/undeveloped”)andhierarchies(“developing”),
transforming wants into needs, Pluriverse is the book that you didn’t
know you wanted, yet once opened, you will recognize that you need
it to make sense of our cascading global crises.
Book details:
New Delhi: Tulika Books/
New York, NY: Columbia University Press, October 2019
ISBN: 9788193732984
384 Pages
Format: Paperback
List Price: $35.00/£28.00
Web Link: http://cup.
columbia.edu/book/
pluriverse/9788193732984
REFERENCES
1. Di Nicola VF. De l’enfant sauvage à l’enfant fou: A prospectus
for transcultural child psychiatry. In: Grizenko N, Sayegh L,
& Migneault P (Eds), Transcultural Issues in Child Psychia-
try. Montréal, QC: Éditions Douglas; 1992. p. 7-53.
2. Di Nicola V. Take your time: Seven pillars of a slow thought
manifesto. Aeon (online magazine). February 27, 2018.
Available from: https://aeon.co/essays/take-your-time-the-
seven-pillars-of-a-slow-thought-manifesto. [Last accessed
on 2022 Dec 12.]
3. Di Nicola V. The Global South: An emergent epistemolo-
gy for social psychiatry. World Soc Psychiatry 2020;2:20-6.
Available from:
4. https://www.worldsocpsychiatry.org/text.asp?2020/2/1/20/281130.
5. Gramsci A. Selections from the Prison Notebooks, ed. &
trans. by Hoare Q & Nowell Smith G. New York, NY: Inter-
national Publishers; 1971 [1930].
6. Illich I. Tools for Conviviality. New York: Harper and Row;
1973.
7. Malthus RM. An Essay on the Principle of Population, as it
affects the future improvement of society with remarks on
the speculations of Mr. Godwin, M. Condorcet, and other
writers.
8. London: J. Johnston; 1803. (Published anonymously in
1798, later acknowledged by Thomas Robert Malthus in the
second edition in 1803). Available from:
9. https://www.gutenberg.org/cache/epub/4239/pg4239-im-
ages.html. [Last accessed on 2022 Dec 12].
10. Meadows DH, Meadows, DL, Randers J, Behrens III, WW.
The Limits to Growth; A Report from the Club of Rome’s
Project on the Predicament of Mankind. New York: Uni-
verse Books; 1972.
11. Poerksen U. Plastic Words: The Tyranny of a Modular Lan-
guage, trans. by Mason J, Cayley D. University Park, PA: The
Pennsylvania University Press; 1995.
12. Sachs W. The Development Dictionary: A Guide to Knowl-
edge as Power. London: Zed Books; 1992.
13. Tomasi di Lampedusa G. The Leopard, trans. by Colquhoun
A. New York, NY: Pantheon Books; 1960.

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