Severe mental disorders in rural China: a longitudinal survey

Background

Little is known about the change in long-term prevalence of mental disorders during a period of sustained rapid socioeconomic development. Here we explore the prevalence change of severe mental disorders in a 21-year longitudinal study in a rural area of China.

Public nutrition in complex emergencies

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.     

Mental health in complex emergencies

Mental health is becoming a central issue for public health complex emergencies. In this review we present a culturally valid mental health action plan based on scientific evidence that is capable of addressing the mental health effects of complex emergencies. A mental health system of primary care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care. This plan emphasises the need for standardised approaches to the assessment, monitoring, and outcome of all related activities. Crucial to the improvement of outcomes during crises and the availability to future emergencies of lessons learned from earlier crises is the regular dissemination of the results achieved with the action plan. A research agenda is included that should, in time, fill knowledge gaps and reduce the negative mental health effects of complex emergencies.     

Globalisation, complex humanitarian emergencies and health

A new political economy of conflict has emerged in the aftermath of colonialism and the Cold War. Complex political emergencies have been simmering in the post-colonial world for more than three decades. Intra-country armed conflict, often combined with natural disasters, at present contributes to the displacement of over 20 million people world-wide. The international community remains profoundly uncomfortable with the complex political emergencies of the new era, torn between the respect for national sovereignty upon which the international political system of the United Nations and other agencies is built, and the growth of concern with human rights and a burgeoning International Humanitarian Law.Globalisation may have brought many benefits to some but there are also many losers. The Word Bank and the International Monetary Fund imposed structural adjustment policies to ensure debt repayment and economic restructuring that have resulted in a net reduction in expenditure on health, education and development. A downward spiral has been created of debt, disease, malnutrition, missed education, economic entrapment, poverty, powerlessness, marginalization, migration and instability. Africa's complex political emergencies are particularly virulent and tenacious. Three examples that are among the most serious humanitarian emergencies to have faced the world in recent times--those in Angola, the Democratic Republic of Congo and Sudan--are reviewed here in detail. The political evolution of these emergencies and their impact on the health of the affected populations are also explored.     

Communicable diseases in complex emergencies: impact and challenges

Communicable diseases, alone or in combination with malnutrition, account for most deaths in complex emergencies. Factors promoting disease transmission interact synergistically leading to high incidence rates of diarrhoea, respiratory infection, malaria, and measles. This excess morbidity and mortality is avoidable as effective interventions are available. Adequate shelter, water, food, and sanitation linked to effective case management, immunisation, health education, and disease surveillance are crucial. However, delivery mechanisms are often compromised by loss of health staff, damage to infrastructure, insecurity, and poor co-ordination. Although progress has been made in the control of specific communicable diseases in camp settings, complex emergencies affecting large geographical areas or entire countries pose a greater challenge. Available interventions need to be implemented more systematically in complex emergencies with higher levels of coordination between governments, UN agencies, and non-governmental organisations. In addition, further research is needed to adapt and simplify interventions, and to explore novel diagnostics, vaccines, and therapies.     

Common mental disorders in postconflict settings

Research into postconflict psychiatric sequelae in low-income countries has been focused largely on symptoms rather than on full psychiatric diagnostic assessment. We assessed 3048 respondents from postconflict communities in Algeria, Cambodia, Ethiopia, and Palestine with the aim of establishing the prevalence of mood disorder, somatoform disorder, post-traumatic stress disorder (PTSD), and other anxiety disorders. PTSD and other anxiety disorders were the most frequent problems. In three countries, PTSD was the most likely disorder in individuals exposed to violence associated with armed conflict, but such violence was a common risk factor for various disorders and comorbidity combinations in different settings. In three countries, anxiety disorder was reported most in people who had not been exposed to such violence. Experience of violence associated with armed conflict was associated with higher rates of disorder that ranged from a risk ratio of 2.10 (95% CI 1.38-2.85) for anxiety in Algeria to 10.03 (5.26-16.65) for PTSD in Palestine. Postconflict mental health programmes should address a range of common disorders beyond PTSD.     

Metabolic syndrome in severe mental disorders

The concept of metabolic syndrome in psychiatry provides a united front for confronting a series of metabolic changes that are predictive of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM), which are highly prevalent in severe mental disorders (SMDs), such as schizophrenia, bipolar disorders, and severe depression. This review attempts to answer the following questions: (1) Is there evidence of significantly increased risk of metabolic syndrome in SMDs? (2) How is this evidence explained by stress theory and functional polymorphism? (3) What role can psychopharmacology and psychosocial therapies play in minimizing the problem? We have done a historical review using related literature from Medline. Compared with the general population, metabolic syndrome is two to three times more common in SMDs. The evidence for this predates the era of antipsychotic drugs. Altered glucose metabolism and dyslipidemia seem to be integral to SMDs. However, major psychotropic drugs are associated with metabolic syndrome, because of their activity at the appetite-stimulating receptors. SMDs seem to trigger a pathogenic cycle that fuels metabolic syndrome. To explain these findings, a neural diathesis-stress model has been proposed. Furthermore, candidate genes associated with receptors for weight gain are implicated. Using metformin (≥750?mg/day) may significantly reduce metabolic risks, and the data support consideration of this intervention for psychiatric patients taking antipsychotics. The obstacles to the implementation of the available guidelines for monitoring metabolic effects and changing unhelpful lifestyles need to be overcome by making monitoring mandatory and integration of physical exercise into routine care. Drug development and genotyping for the risk factors are future solutions.     

Lessons learned from complex emergencies over past decade

Major advances have been made during the past decade in the way the international community responds to the health and nutrition consequences of complex emergencies. The public health and clinical response to diseases of acute epidemic potential has improved, especially in camps. Case-fatality rates for severely malnourished children have plummeted because of better protocols and products. Renewed focus is required on the major causes of death in conflict-affected societies--particularly acute respiratory infections, diarrhoea, malaria, measles, neonatal causes, and malnutrition--outside camps and often across regions and even political boundaries. In emergencies in sub-Saharan Africa, particularly southern Africa, HIV/AIDS is also an important cause of morbidity and mortality. Stronger coordination, increased accountability, and a more strategic positioning of non-governmental organisations and UN agencies are crucial to achieving lower maternal and child morbidity and mortality rates in complex emergencies and therefore for reaching the UN's Millennium Development Goals.     

Haematological emergencies managing hypercalcaemia in adults and children with haematological disorders

Hypercalcaemia is a common metabolic complication of malignant disease often requiring emergency intervention. Although it is more frequently associated with solid tumours, malignancy‐associated hypercalcaemia (MAH) is seen in a significant number of patients with blood diseases. Its association with myeloma and adult T‐cell leukaemia/lymphoma is well recognized but the incidence of hypercalcaemia in other haematological neoplasms, affecting adults and children, is less clearly defined. Haematologists need to be familiar with the clinical manifestations of, the differential diagnosis to be considered and the most effective management strategies that are currently available for MAH. The key components of management of MAH include aggressive rehydration, specific therapy to inhibit bone resorption and, crucially, treatment of the underlying malignancy. Bisphosphonates have revolutionized the management of MAH over the last 20 years, however the elucidation of molecular pathways implicated in MAH is facilitating the development of more targeted approaches to treatment.     

Assistance, protection, and governance networks in complex emergencies

This article presents an introduction to the causes and characteristics of armed conflicts. It reviews some of the key humanitarian crises that broke new ground in terms of the technologies and practices that developed at the field level in response to each new complex emergency, with particular focus on the health sector. It introduces the concept of humanitarian governance as a framework for addressing the consequences and implications of the failure of worldwide governance for the protection of civilians in armed conflict. Here, we term humanitarian governance to include the use of international humanitarian law and human rights instruments to govern the behaviour of state and non-state organisations in conflict zones in a way that protects the lives and livelihoods of affected populations. We note, however, that terrorist concerns appear to be replacing humanitarian logic in the network of worldwide governance.