ficient, insufficient, and not sustainable. In the U.S., with the exception of cognitive behavioral therapy in psychiatric residency training programs, courses in evidence-based psychotherapy are now not an accreditation requirement (12). Certification standards are either absent or ad hoc. Applied public mental health could be a subspeciality of public health and a clinical profession, for which training in brief evidence-based psychotherapies would be essential. Rates of psychiatric disorders, particularly depression and anxiety, are high in primary care patients, and among victims of natural disasters, civil wars, violence, sexual abuse, chronic medical illness, the unemployed, new mothers, recently divorced, etc.. These individuals frequently need social, economic and legal services. In order for these services to be effective, however, the distressed individuals also need a therapeutic alliance and someone to talk to and sort out their history, their resources and concerns. I am not advocating long-term psychotherapy except where it is indicated for the small number of people with severe and enduring psychiatric disorders. In the context of Wahlbeck’s comprehensive proposal, a focus on short-term evidence-based psychotherapy implemented with the guidance of public mental health specialists is modest. The

broader goals should not be lost, recognizing they require advocacy and the public will. In the meantime, however, small but dedicated efforts to improve the delivery of mental health care that are cost-effective and evidence-based should be sought. The guiding principles should include a focus on early intervention, integration with primary care where possible, a patient centered orientation, and an integration of clinical and public health perspectives. It is more efficient to have psychosocial interventions taught in formal educational programs than in grass roots ad hoc training courses. At present, public health programs identify risks but do not teach clinical applications, while social work and other counseling programs are not grounded in public health, and training in evidence-based psychotherapies is rarely required. These disciplines have much to offer each other in bridging the gap.

References 1. Wahlbeck K. Public mental health: the time is ripe for translation of evidence into practice. World Psychiatry 2015;14: 36-42. 2. Cohen N, Galea S (eds). Population mental health: evidence, policy, and public

health practice. New York: Routledge Studies in Public Health, 2012. 3. Woolf S. Social policy as health policy. JAMA 2009;301:1166-9. 4. McHugh RK, Whitton SW, Peckham AD et al. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders. A meta-analytic review. J Clin Psychiatry 2013;74:595-602. 5. Weisz JR, Jensen-Doss A, Hawley KM. Evidence-based youth psychotherapies versus usual clinical care. Am Psychol 2006;61:671-89. 6. Huhn M, Tardy M, Spineli L et al. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. JAMA Psychiatry 2014;71:706-15. 7. Editorial. Therapy deficit: studies to enhance psychosocial treatments are scandalously under-supported. Nature 2012; 489:473-4. 8. World Health Organization: mhGAP intervention guide for mental, neurological, and substance use disorders in nonspecialized health settings. Geneva: World Health Organization, 2010. 9. Weissman M. Psychotherapy: a paradox. Am J Psychiatry 2013;170:712-5. 10. Miller G. Mental health care: who needs psychiatrists? Science 2012;335:1294-8. 11. Weissman MM, Verdeli H. Outsourced psychiatry: experts still relevant. Science 2012; 336:152. 12. Weissman MM, Verdeli H, Gameroff MJ et al. National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry 2006; 63:925-34. DOI 10.1002/wps.20180

Mental disorder: a public health problem stuck in an individual-level brain disease perspective? JIM VAN OS Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, 6200 MD, Maastricht, The Netherlands

K. Wahlbeck provides a range of cogent arguments supporting the view that the natural perspective for mental health is in the realm of public health. In reality, however, the perspective of public health is not dominant in academic psychiatry or in the way mental health

services are organized. The dominant model in academic psychiatry is embedded in an individual-level perspective of brain disease, although there is considerable debate as to how successful this dominant approach has been (1). A student wanting to find out about psychiatry may get the impression that two languages are spoken in mental health: a public health one, taking into account the natural perspectives of high prevalence, graded trajectories from health to illness, social

determinants, empowerment and selfdetermination, resilience, positive mental health and prevention; and a biomedical one, focusing on illness and diagnostic labels, brain disease, animal research, genetic liability, biological determinants and pharmacological interventions. The existence of two languages in mental health research is one of the explanations of the limited crosstalk between areas distributed over the public health and natural sciences, even though 47

the application of scientific paradigms to mental health research, including those derived from neuroscience, psychiatry, public health, epidemiology, social science, sociology, psychology and philosophy, has expanded exponentially. In other words, research in mental health has expanded exponentially, but in widely different directions, showing signs of increasing fragmentation rather than integration. If natural science and public health are to join forces, this will have to be at the level of research endeavours in which the results are interpreted on the basis of a common language. There are some pointers as to which elements may be used to construct a common language. First, research in public health highlights powerful effects of the social environment on onset and persistence of syndromes of mental illhealth, the existence of vulnerable and resilient subgroups, and possible cognitive, neural and behavioural mediation of environmental effects. Second, research in psychology and psychiatry indicates that most mental disorders as defined in DSM and ICD represent quantitative deviation from health. Third, research in basic population genetics highlights the importance of (epi)genetic variation in terms of shortterm and long-term adaptation to the social environment. Fourth, research in social neuroscience is highlighting the role of the brain in enabling man to navigate the social world and is building models of the way in which our current context – which includes both the social environment and our internal states and traits – impacts on how we attach meaning to social cues. There is increasing interest in the role of culture in these processes, for example how cultural variation may impact on social cognition and the process of empowerment in relation to one’s circumstances. The above four elements indicate that genetic variation and neural processes form the biological roots of human sociality, resulting in the mutual constitution of cultures and selves; they also suggest that health and illness result from complex interactions between the physical, cultural, and social environments. Thus,

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a common theme emerges linking deviation from mental health, genetic variation and neural function, which can be formulated as dynamic adaptation to the individual-level and wider social environment. Dynamic adaptation to the environment may constitute a point of entry towards a common language in mental health research, linking social and natural sciences. However, this perspective contrasts with the current practice of research in biological psychiatry, which typically involves comparisons between a group of severely ill patients constrained by DSM or ICD criteria of disorder, and healthy, or “super-healthy”, controls on static measures of, for example, allelic frequency or cortical thickness. In other words, the role of genetic and neural variables in dynamic adaptation to the social world, including at the level of intentionality and meaning, is typically not taken into account. Public health approaches in mental health research can be introduced focusing on genetics, neuroimaging and animal models, using the perspective of dynamic adaptation to the environment. For example, what potentially links the different approaches in mental health research is the level at which social and cultural influences are studied, and how these might interact with each other. Public health research is of particular interest in the area of how the wider social environment may impact on risk for and resilience against mental disorders. Examples of such contextual variables are social cohesion and trust, social capital, social integration, ethnic density, population density, social divide or social inequality. Research has shown that these types of contextual variables are strongly associated with mental outcomes (risk and resilience), and interact with individual-level characteristics (e.g., individual-level ethnic group and ethnic density). As there is a paucity in crossdiscipline approaches, this type of research has yielded little in terms of causality, biological and psychological mediators and moderators, and devel-

opmental pathways. It is reasonable to assume that the impact of the wider social environment will be mediated by individual-level cognitive and (crossspecies) biological factors and that it will be moderated by the same factors. It is clear that a rich potential exists for collaboration between public health scientists on the one hand, and mental health and neuroscience researchers on the other. While it may be attractive to align cross-species behavioural research paradigms, resulting in a multilevel perspective on underlying neural mechanisms, there is an additional need to co-align and co-evaluate this work with “mental” paradigms, for example from experimental psychology. A good starting point to bring together research on behavioural, neural and cognitive mechanisms around a single paradigm is to study the impact of a certain environmental exposure (at the level of repeated within-person momentary micro-environment, the individual level, or the contextual level of the wider social environment) on mental, behavioural, neural, cellular and molecular outcomes in a single observational or experimental “social” paradigm, taking into account moderation of environmental influence by genetic factors. For example, childhood adversity and having a minority position in society are important social risk factors with powerful effects that can be described in terms of developmental mental, molecular, cellular, neural circuit, cognitive and behavioural effects, in association with evidence of moderation by genetic variation. Bringing these together in a single collaborative research effort, linking the different mechanisms, will make it possible to enrich the outcome of individual research efforts synergistically.

Reference 1. Kapur S, Phillips AG, Insel TR. Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it? Mol Psychiatry 2012;17:1174-9. DOI 10.1002/wps.20181

World Psychiatry 14:1 - February 2015

Mental disorder: a public health problem stuck in an individual-level brain disease perspective?

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