BACKGROUND: There is an urgent need to provide training and tools to frontline health workers in order for them to properly diagnose and treat mental illnesses in Latin-American communities, since the vast majority of people with a mental illness suffer in silence. A computer-assisted interview, the Global Mental Health Assessment Tool (GMHAT/PC) has been developed to assist general practitioners and other health professionals to make a quick, convenient, yet reasonably comprehensive and standardised mental health assessment. GMHAT/PC has been translated into various languages including German, Dutch, Chinese, Hindi and Arabic. This is the first study, of a GMHAT/PC Spanish version carried out in Latin America, to establish its validity in that culture and feasibility to be used in the health care setting. If proven a valid tool through this study, the GMHAT/PC Spanish version will be an important aid towards improving the mental health of Spanish-speaking communities within the Latin-American region. AIM: The study aims at assessing both the validity of a GMHAT/PC Spanish version, and the feasibility of utilising a computer assisted diagnostic interview by GPs. DESIGN: 1) Validation study was planned to establish whether the GMHAT/PC based diagnosis compares well with the consultants ICD-10 based diagnosis (Gold Standard) 2) Feasibility study was carried out to examine whether GMHAT/PC can be used in routine clinical care in a general health setting. MATERIALS AND METHODS: In the first study (validation), participants varied from those who were in remission i.e. without much psychopathology to those had symptoms of a severe mental illness. They were recruited from in-patient (82%) and out-patient (18%) mental health settings in Colombia. The participants were expected to have a wide range of psychiatric diagnoses (anxiety disorders, depression, psychosis, bipolar affective disorder, organic mental disorders, and other diagnoses). All consecutive patients were interviewed by GPs using GMHAT/PC and psychiatrists made an independent diagnosis applying ICD-10 criteria. The second study (feasibility) was carried out on patients hospitalised at medical, surgical and women’s wards during a period of one month in each service. The diagnosis of a medical illness was made by specialists in each service. A trained GP carried out psychiatric assessment of all participants using GMHAT/PC. RESULTS: First study (validity): two hundred ninety-nine patients (n=299) participated, 54.18% males and 45.81% females in the age range of 14-78. All patients were interviewed independently by seven psychiatrists with over five years of clinical experience. The mean duration of GMHAT/PC interview was 12.5 minutes. Most patients were pleased that they were asked about every aspect of their mental health. Psychiatrists made a single diagnosis in 183 (61%) cases, multiple (two) diagnosis in 112 (37%) cases and multiple (three) diagnosis in another four cases. GMHAT/PC in almost all cases gave additional multiple diagnoses. The results show an acceptable-to-good level of agreement between the GPs’ (GMHAT/PC) diagnoses and the psychiatrists’ (clinical) diagnoses of any mental illness, Kappa 0.58- 95% C.I (0.46, 0.72). There is a good level of sensitivity (81%) and specificity (92%), with GPs correctly identifying 242 out of the 250 participants diagnosed with a mental illness, and 27 out of 35 of those who do not present any whatsoever. The agreement (kappa value) between GMHAT/PC diagnosis and psychiatrists ICD-10 based diagnosis of specific disorders were as follows: Organic disorders-0.87; Psychosis- 0.56; Depression-0.53; Mania-0.6, Alcohol and drug misuse- 0.62, Learning disorder- 0.4; Personality Disorder- 0.39 and Anxiety disorders- 0.14. The sensitivity of different disorders ranged from 63% (Mania) to 100% (Anxiety) and specificity from 71% (Anxiety) to 100% (organic). The second study (feasibility): out of 455 medically-ill patients, 4.8% had a mental illness identified by GMHAT/PC interview. Anxiety, depression and organic disorders were the most frequently identified mental disorders in internal medicine and surgery. Cancer had a significantly higher prevalence of comorbid mental illness. CONCLUSION: GMHAT/PC -Spanish version used by GPs in this study detected mental disorders accurately and it was feasible to use GMHAT/PC in Colombia and Latin-American health settings. The findings of this study will have a big impact upon mental health service provision in Spanish-speaking nations within the Latin-American region as the Spanish version for GMHAT/PC will assist primary care physicians and other health workers in detecting and managing mental health disorders in the communities. There is no other comparable easy-to-use comprehensive mental health diagnostic tool available in Spanish.

Bullying, harassment, and horizontal violence (BHHV) is commonly reported by student nurses during their clinical education. Despite decades of mention in the literature, no instrument is available to specifically measure the student nurse's experience of BHHV during clinical education. Purpose: The purpose of this dissertation is to examine the experience of BHHV in a population of student nurses matriculating during their clinical education in New York. The experience of BHHV is measured with the BEHAVE Survey, the instrument developed and tested for this purpose. Methods: This dissertation is presented in three manuscripts: (1) a comprehensive review of the literature using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement as the methodological guide, (2) the initial psychometric testing of BEHAVE (Bulling, harassment, and HorizontAl ViolencE) for validity and reliability at a university-based school of nursing in New York, and (3) a descriptive, quantitative survey of baccalaureate nursing students at a university-based school of nursing in New York completed as a field test of the BEHAVE. Results: Despite variations in methodology, measurement, terms, definitions, and coding of behaviors and sources of BHHV, the findings of this literature review indicate that student nurses are common targets of BHHV during clinical education, regardless of demographic characteristics, disability, sexual orientation, geography location, academic institution or program type. Psychometric testing indicated: scale-level content validity index among experts 0.89, r = 0.97, a Cronbach's á 0.94, and percent agreement 93% in test-retest reliability. BEHAVE was administered to a total of 32 participants (96.7% participation rate). Approximately 72% reporting current experienced or observed BHHV with 46.8% (36/77) of incidents originated from a nurse. Conclusions: The evidence from both the literature and this field trial suggests that BHHV is a common experience among nursing students. This is significant because student nurses are vulnerable to BHHV and studies including students have been limited to date. Therefore, it behooves the research community to continue to explore the impact of BHHV on the student nurse's socialization into the professional nursing role. Further knowledge may inform targeted interventions to reduce BHHV and improve the ability of nursing students to minimize the impact of BHHV should it occur.

This dissertation presents an ethnography of equine-assisted psychotherapy (EAP) based on nine months of fieldwork at "Equine Healers," a non-profit organization in central Colorado that specialized in various therapeutic modalities associated with EAP. In bridging scholarly work around animals, a literature suffused with the notion of "companion species," as well as scholarly work around psychotherapy, and most especially the idea of "psychotherapy as conversation," the connective conflict these two interests share, and from which this dissertation emerges, is over questions of language and communication. Specifically, the overarching problem that this dissertation addresses is: what counts as talking, in the context of "the talking cure," when beings that do not share human language are necessarily implicated in human conversations. Beginning with Das' (1997) encouragement to understand "pain as the beginning of a language game," most of this dissertation will therefore be about dropping the reader into the silences between the humans and the horses, and between the words the humans use to talk about their experiences with the horses, thereby raising fundamental questions about the communicational dialectics that can transform human experiences. I argue that anthropologists must re-arrange our analytical frames around humans and animals, beginning with how we understand language, in the context of communication, to be organized. Rather than privileging subjects and objects, I suggest returning to Bateson (1972) and attempting to privilege relationships. To explore these ideas, this dissertation will attend to a particular therapeutic modality employed at Equine Healers, a set of practices called a "group sculpture." To set up and make it possible to appreciate the complexity of this modality, this dissertation will first consider framing conversations among humans and horses as rhythmically ordered interactions. To do this, I generate a model of conversation based less on grammatical rules derived from the use of words, or the possibilities offered by subject-object "thing" relationships, and instead lean on musical relationships of rhythm. Initially emerging through conversation, I then trace out rhythms carried between horses and humans by particular physical, material pieces of their world. These brushes, clickers, and bridles ultimately bridge vocal and pneumatic rhythms; and it is movement along this connection, an ebb and flow of voice and breath that, in aligning, generate opportunities for iconic relationships with one's self.

Prenatal maternal depression and anxiety are associated with poor infant health, behavioral and achievement outcomes. The impacts of prenatal maternal mental health on the development of particular brain-based neurocognitive systems in children are less clear. This dissertation examines the association between prenatal maternal depression and anxiety and infant memory and language outcomes. 179 infant mother dyads were recruited in South Dakota. Ninety infants were followed at 9- and 15-months, and 89 were followed at 15- and 21-months of age. These data were used to understand more clearly the association between prenatal maternal depression and anxiety and changes in infant memory and language over the first two years of life. Additionally, by measuring the interaction between prenatal mental health and parenting and the direct association of parenting on changes in infant memory and language, we can better understand if the pathway between prenatal maternal mental health and infant memory and language is biological, social or both. Results demonstrated no significant direct association between prenatal maternal depression and anxiety symptoms and changes in infant memory or language from 9 to 21 months. The HOME language and literacy subscale was associated with changes in memory and language from 9 to 21 months; the HOME parental warmth subscale was associated with changes in language from 9 to 21 months. These results were independent of prenatal maternal social risk. Implications for additional screening measures, interventions, and considerations for future research are discussed.

Working with HIV-positive individuals may present a particular challenge to clinicians because of the phenomenon of stigma. Researchers have proposed that HIV stigma is layered with people's prejudiced attitudes toward already-stigmatized groups (e.g., sexual orientation, gender, race and ethnicity) in which people living with HIV/AIDS may have membership. Previous research has suggested that, clinicians' attitudes and reactions toward HIV and sexual orientation may significantly impact their therapeutic impressions, yet questions remain with regard to how clients' HIV status and racial identity may operate in confluence to influence clinicians' therapeutic impressions. This question may be particularly significant with regard to mental health professionals, as research also suggests that racial/ethnic minority clients can be perceived by their clinicians as more disturbed as a result of clinicians' biased racial attitudes. In the present study, case vignettes featuring hypothetical Black or White men who are either HIV-positive or HIV-negative were presented to participants to explore the influence of a client's HIV status and race upon participants' therapeutic impressions. Results indicated that participants' expectations of therapeutic process and evaluations of the clients' symptomatology were influenced by the clients' race and HIV status. Participants expected slightly greater session depth for the Black clients than the White clients in the vignettes, and their initial impressions of symptomatology were also slightly more negative toward the White clients in the vignettes. With regard to the main effect of client HIV status, participants expected slightly greater session depth for the HIV-positive clients than the HIV-negative clients in the vignettes. However, participants expected slightly less session smoothness for the HIV-positive clients in the vignettes, and they also reported lower assessment of psychological, occupational, and social functioning toward the HIV-positive clients in the vignettes. The potential interaction of the hypothetical client's race and HIV status and its effect upon participants' clinical impressions was not found significant. Implications for research and practice are discussed.

In recent years, problem use of classified prescription drugs in the United States has become a critical public health concern garnering increased attention and resources. Although the focus has primarily been on problem use of prescription drugs with the highest abuse potential, evidence of the increasing prevalence and growing burden of problem benzodiazepine use in the United States is mounting. Most epidemiological research on problem prescription drug use, including benzodiazepines, has focused on use among individuals without a prescription. However, problem use also includes use with a prescription, but in ways, or for reasons, not recommended by a doctor. Of particular importance are individuals with a benzodiazepine prescription who experience clinically significant impairment or distress as a result of using their prescription in problematic ways. Several prescription-related risk factors could increase the risk of problem benzodiazepine use among individuals prescribed benzodiazepines. These include characteristics of the benzodiazepines prescribed (including dosage and abuse liability of the prescribed benzodiazepine), the amount of benzodiazepine prescribed over time (including medication possession ratio [i.e. whether the benzodiazepine recipient has more medication than is medically necessary] and days supply of medication) and prescription contextual variables (including whether the prescription recipient also receives other controlled substances and utilizes psychotherapeutic services). In addition, characteristics of the benzodiazepine prescription recipient (including alcohol disorders, drug disorders, anxiety disorders and mood disorders) could also predict problem benzodiazepine use. This dissertation aims to consider the independent and joint roles of these factors in the risk of problem benzodiazepine use among individuals with a prescription. To this end, the current dissertation consists of three parts: a systematic literature review and two analytic research papers investigating risk factors for the development of problem benzodiazepine use, using prospective individual-level medical and pharmacy claims information in the 2003-2004 Thompson Reuters MarketScan® Commercial Claims Databases. Modifiable variables including prescription characteristics, the amount of benzodiazepine prescribed over time and prescription contextual factors independently increased the risk of problem benzodiazepine use among individuals with a prescription. Psychiatric disorders, for which benzodiazepines are indicated (alcohol and anxiety disorders), or used off-label (drug and mood disorders), independently increased the risk of problem benzodiazepine use among individuals with a prescription. Further, psychotherapy and opioid prescriptions modified the increased risk of problem benzodiazepine use conferred by an anxiety disorder. This information can be used to develop specifically targeted prevention and treatment interventions, such as surveillance systems, to address the burden of problem benzodiazepine use in the U.S.

An increasing number of clients are seeking admission to state mental hospitals to satisfy non-psychiatric needs. The study describes this phenomenon, its possible causes and its consequences. The study draws profiles of these clients' characteristics, problems, needs, and level of functioning. Clients' expectations from the state hospital and differences between them and the hospital inpatient population are explored. The study was conducted on a time sample of 100 clients who sought admission to a New York State psychiatric center. The client sample were found not in need of inpatient treatment and were referred to an emergency housing program. Data were gathered through structured and unstructured questionnaires, interviews with clients, staff, center officials, and the center's statistical and patients' records. Chi-Square Test and Spearman Correlation were used to test relationships between variables. Study data indicated that: (1) The majority of clients were young, white, single, males, unemployed, educated below high school level, and were living with a relative or a friend at the time they appeared for admission. (2) Client's self assessment and staff assessment of clients' needs suggested that housing and financial aid were significant to more clients than psychiatric treatment. (3) Client's self assessment and staff assessments of individual client's level of functioning indicated that the majority of clients were able and willing to live independently in community settings. (4) The majority of clients sought admission to the psychiatric center expecting help with housing, financial and emotional problems in that order. (5) Client sample and patients admitted to the center during the same period did not differ significantly with regard to age, sex, race, religion and marital status. The two populations differed in admission status, educational level, employment status, and sources of referral to the Center. The study recommended a clear boundary distinction of psychiatric and non-psychiatric services and that psychiatric admission be based on psychiatric rather than social factors. The study also recommended several policy and planning options in dealing with the problem. A major option was the initiation of local personal social service centers to service clients with non-psychiatric problems.

Following a rise in people 'speaking out' about their recovery and thus challenging traditional psychiatric ideas of chronicity, the recovery approach has become a central guiding vision within mental health services. This thesis comprises two parts. The first part applies a genealogical method to conduct a genealogical analysis of the recovery approach through exploration of UK policy within the last decade. This explores the conditions of possibility for its emergence in UK policy and mental health services and its growth. In the second part, a Foucauldian discourse analysis is used to analyse stories of recovery. Recovery stories are collected from organisational websites in the third sector and public sector. Subject positioning and power/knowledge implications are discussed in light of eleven discursive constructions: personal interpretation, person al responsibility, socioeconomic opportunity, self - management, an ongoing process, expertise and sharing stories, professional embodiment, fulfilment through work, living well without work, acceptance of illness and acceptance by others. These 'personal' testimonies might reflect wider discourses in the mental health system. The research shows the powerful interests at play under the discourse of recovery, and the promotion of particular 'truths' that this brings with it. Counter to this are smaller sites of resistance. Implications are discussed for clinical practice and further research.

Dementia and caregiving have received increasing research, clinical and political attention over the past forty years. However, such attention has been particularly focused on understanding the biomedical markers and interventions for dementia within majority populations. Little attention has been afforded to understanding alternative conceptualisations of dementia particularly from varying cultural and religious lens’. Existing research which has attempted to explore cultural understandings of dementia has done so in a homogenising manner and masked potential nuances between different cultures and religions. Research has also tended to shy away from exploring the impact of dementia upon spousal relationships. Given spouses (predominately wives) have been shown to deliver much of dementia caregiving this is an important area to illuminate, both for its clinical and moral implications. Taking in to account these two distinct gaps in knowledge, the present study aimed to explore the experiences and meanings of Punjabi Sikh wives in living with husbands who have a label of dementia. This study adopts a grounded theory methodology to explore the experiences of Punjabi Sikh wives living with husbands who have been given a diagnosis of dementia. Based on the accounts of eleven wives, a model was generated which revolved around the various processes associated with living with a husband with dementia. The emergent model consisted of three distinct, yet interacting theoretical processes, the wives’ responses, systemic responses and resistive responses. The wives’ responses centred around how they acknowledged, understood and ultimately lived with changes they experienced in their husbands and themselves. The systemic responses outlined the ways in which participants perceived their wider system to negate their responses through, ignoring, misunderstanding and denying the changes in their husbands. Finally, participants recounted their resistive responses against such systemic pressures. Based on the accounts of the participants, implications for clinical practice and future research are discussed.

The research is a qualitative exploration of perceptions of adolescent mental health and collaborative working concerning this. There are rising numbers of young people with difficulties relating to mental health and a need to develop closer links between services and schools has been identified (Department for Education, 2015b). However, there is not enough known about how agencies work together, despite their differences, in order to effectively support adolescent mental health. Part one utilised semi structured interviews to explore, in depth, how, educational psychologists (EPs), Children and Adolescent Mental Health Service (CAMHS) professionals and secondary school staff view adolescent mental health with regards to issues, practices, collaboration and how they view their own and other’s roles in supporting young people with mental health difficulties. Part two consisted of discussion groups guided by the use of vignettes, in order to explore the ways in which, EPs, CAMHS professionals and secondary school staff problem solve both in their own professional group and in a multi-agency group to explore the commonalities and differences in this. Findings from part one indicate that there are differences in perceptions of adolescent mental health across these three groups, with particular regards to their own and each other’s roles. Further to this findings indicate a lack of a shared understanding, characterised by a level of departmentalism. Findings from part two indicate that there are significant differences between the way in which schools, EPs and CAMHS professionals make sense of cases and in the way in which they work in their own professional group compared to how they work in multiagency groups. There were also indications that the differences that were found between groups in both part one and two, actually worked to increase the effectiveness of the approach in the multiagency groups, creating an enhanced and richer understanding of the problem given. Overall findings indicate that although on the surface thinking appears similar there are significant differences in thinking across EPs, CAMHS and schools in this area. Implications and recommendations for practice include; developing clarity and transparency regarding roles and fostering closer links by developing a shared understanding through opportunities for joint training.