Includes abstract. Includes bibliographical references.

ABSTRACT Background: Tremendous progress has been achieved in the treatment for HIV/AIDS since the 1980s. This significant improvement and progress in HIV treatment has largely been attributed to antiretroviral therapy (ART). Non-adherence to ART commonly causes ART treatment failure and the development of drugresistant strains of HIV, resulting in increased mortality. Common mental disorders have been found to be strongly associated with non-adherence. In Malawi, where HIV is prevalent, there is a paucity of studies on how common mental disorders are associated with non-adherence. The present study aimed at examining the association between depression, anxiety and alcohol use disorder symptoms and ART adherence among people living with HIV/AIDS (PLWHA) attending an HIV clinic in Blantyre, Malawi. Methods: This was a facility-based quantitative study with a cross-sectional descriptive design with 213 PLWHA attending an HIV clinic. The participants completed a survey consisting of demographics and mental health disorders symptoms screening tools, namely the 9-item Patient Health Questionnaire (PHQ9) for depression symptoms, the Generalized Anxiety Disorder 7-item scale (GAD-7) for anxiety symptoms and the Alcohol Use Disorders Identification Test (AUDIT) for alcohol use and related harms. ART adherence was assessed using pill count, a self-report measure and a combined measure of both pill count and self-report adherence. Results: The prevalence of depressive symptoms among the participants was 32%, 26% for anxiety symptoms and 16% of participants reported any life-time alcohol use. The majority of participants (75.6%) were found to have good pill count-based adherence while only 41.7% and 33.2% of participants reported good adherence on the self-report and combined measures respectively. The results showed that older participants were more likely to self-report good adherence than younger participants (OR=1.03; 95%CI=1.01-1.06, p-value=0.050). The participants who scored higher on the AUDIT were less likely to self-report good adherence to ART (OR=0.88; 95% CI=0.78-1.00, p-value=0.050). Side-effects were statistically significantly associated with both pill-count and combined adherence. The participants that experienced side effects from the treatment were less likely to be adherent on pill count (OR=0.19; 95% CI=0.07-0.53, p-value=0.001) and the combined adherence measure (OR=0.45; 95% CI=0.24-0.83, pvalue=0.011). Alcohol use was again significantly associated with combined adherence. The participants who reported ever having used alcohol were less likely to be adherent to ART on the combined adherence measure (OR=0.51; 95% CI=0.29-0.93, p-value=0.026). No statistically significant association between depressive and anxiety symptoms and ART adherence was found. Conclusion: The findings show that symptoms of common mental disorders were highly prevalent among PLWHA. Alcohol use, younger age group and experiencing side-effects from ART were significantly associated with ART non-adherence. Further research is required to investigate how depression and anxiety is associated with ART adherence among PLWHA in a Malawian population using larger sample sizes. The current study also highlights the need to routinely screen PLWHA for mental health problems. Further research using advanced designs, such as randomized clinical trials incorporating implementation science approaches, is also needed to evaluate the feasibility and effectiveness of integrating mental health services into HIV care in Malawi.

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京都大学 / 新制・課程博士 / 博士(地域研究) / 甲第24117号 / 地博第306号 / 新制||地||119(附属図書館) / 京都大学大学院アジア・アフリカ地域研究研究科東南アジア地域研究専攻 / (主査)教授 古澤 拓郎, 准教授 坂本 龍太, 准教授 小坂 康之 / 学位規則第4条第1項該当 / Doctor of Area Studies / Kyoto University / DGAM

<p>The comprehensive aim of the dissertation is to examine how ideas about mental hygiene have been elaborated and debated within the context of Swedish welfare. The dissertation is a compilation of four articles where issues of mental hygiene are examined in detail through an analysis of texts. In addition, a theoretical and methodological framework and a discussion of the concepts of mental health and normality are asserted to the dissertation. The subjects of research are (1) the launching of the movement in USA in the early twentieth, and the autobiographical narrative "A Mind That Found Itself" (Beers 1908), (2) the conception and the evolution of the movement in Sweden, (3) the psychosocial training within the education of social workers between the years 1939 –1989, and (4) the debate about the Mental health Campaign in 1969. The issues of mental hygiene and mental health discussed in the articles are elaborated in relation to the academic disciplines of Sociology of Health and Illness and the History of Public Health. The theoretical approach of these disciplines proceeds from a post-structural and social constructivist perspective of knowledge and language, a perspective also used in the interpretation of the textual materials. The section where the research methods are presented, consists of a description of how the textual materials have been selected and treated in relation to the theoretical and methodological standpoints.</p><p>The outcome of the investigation of the autobiographical book</p><p>"A Mind That Found Itself" (Beers 1908) in relation to the launching of the movement in the USA, is that the monomyth-character of the story supported an image of victory and hope, important for the movements aims to improve the reputation of psychiatry. Concerning the launching of the mental hygiene movement in Sweden two important conditions stands out as the course behind the rather hesitant start: the dominant position of custodial care and the antagonistic attitude towards psychoanalytical theories. The study of the psychosocial training of social workers showed how the skills of the clinical gaze were taught to the students by the technique of case-writing. The study of the Mental Health campaign in 1969 showed important divergences concerning the opinions of normality. Since the individual anatomy in the welfare system in Sweden is organised through the individuals position within the labour market, the issues of mental health and allied opinions of normality also contained the risks of exclusion. In conclusion, a comprehensive reflection concerning the results of the studies, is that the concept of mental hygiene, due to the mix of psychiatric and social knowledge, mediated shifting ideas about normality.</p>

The comprehensive aim of the dissertation is to examine how ideas about mental hygiene have been elaborated and debated within the context of Swedish welfare. The dissertation is a compilation of four articles where issues of mental hygiene are examined in detail through an analysis of texts. In addition, a theoretical and methodological framework and a discussion of the concepts of mental health and normality are asserted to the dissertation. The subjects of research are (1) the launching of the movement in USA in the early twentieth, and the autobiographical narrative "A Mind That Found Itself" (Beers 1908), (2) the conception and the evolution of the movement in Sweden, (3) the psychosocial training within the education of social workers between the years 1939 –1989, and (4) the debate about the Mental health Campaign in 1969. The issues of mental hygiene and mental health discussed in the articles are elaborated in relation to the academic disciplines of Sociology of Health and Illness and the History of Public Health. The theoretical approach of these disciplines proceeds from a post-structural and social constructivist perspective of knowledge and language, a perspective also used in the interpretation of the textual materials. The section where the research methods are presented, consists of a description of how the textual materials have been selected and treated in relation to the theoretical and methodological standpoints. The outcome of the investigation of the autobiographical book "A Mind That Found Itself" (Beers 1908) in relation to the launching of the movement in the USA, is that the monomyth-character of the story supported an image of victory and hope, important for the movements aims to improve the reputation of psychiatry. Concerning the launching of the mental hygiene movement in Sweden two important conditions stands out as the course behind the rather hesitant start: the dominant position of custodial care and the antagonistic attitude towards psychoanalytical theories. The study of the psychosocial training of social workers showed how the skills of the clinical gaze were taught to the students by the technique of case-writing. The study of the Mental Health campaign in 1969 showed important divergences concerning the opinions of normality. Since the individual anatomy in the welfare system in Sweden is organised through the individuals position within the labour market, the issues of mental health and allied opinions of normality also contained the risks of exclusion. In conclusion, a comprehensive reflection concerning the results of the studies, is that the concept of mental hygiene, due to the mix of psychiatric and social knowledge, mediated shifting ideas about normality. / <p>At the time of the doctoral defence the following papers were unpublished and had s status as follows: Papar nr. 1: Manuscript; Paper nr. 3 Accepted Manuscript; Paper nr. 4: Manuscript.</p>

This thesis argues that current treatment in acute public mental health services is counterproductive for the wellbeing of those subject to such services. The consumer/survivor movement activism against the coercive nature of treatment is analysed according to new social movement theory. According to social theorists such as Alaine Touraine, new social movements are characterised by a struggle over identity. Consistent with this theme, what is identified in this thesis as central to the consumer/survivor movement objection to the nature of treatment in acute public mental health services, is the failure of services to respect patient identity as persons. What might account for this failure is analysed in this thesis through an examination of the question of the conceptualisation of the subject in the theory and concepts of psychiatry, in the practice of psychiatry, in mental health law and in government policy. / As a counterposition to the above perspectives, the work of RD Laing, Charles Taylor and Paul Ricoeur are considered in an attempt to develop a conceptualisation of the subject grounded in a historical narrative. Further, Emmanuel Levinas’ and Axel Honneth’s work is drawn on to identify the practical implications of Honneth’s claim for a politics of recognition, which also supports the consumer/survivor movement demand for recognition as subjects in mental health services.

No description available.

Made available in DSpace on 2016-06-02T20:44:17Z (GMT). No. of bitstreams: 1 6672.pdf: 3176723 bytes, checksum: 850e0de36e0862a804ac63c3a8ea3cb3 (MD5) Previous issue date: 2015-02-25 / Financiadora de Estudos e Projetos / The National Curriculum Guidelines for the Bachelor s degree in Occupational Therapy (Diretrizes Curriculares Nacionais do Curso de Graduação em Terapia Ocupacional (DCNTO) in Brazil was created in 2001 and had as one of its propositions the development towards public health. During this time, with the creation of territorial services, the mental health care started to be based on the Psychosocial Rehabilitation assumptions. Recent studies have shown that students who have finished Occupational Therapy (OT) undergraduation and work in the field of mental health report that theoretical and practical training given throughout undergraduation was not adequate facing the real demand. This study aims to understand the real condition of occupational therapists training during undergraduation and its connection with Brazilian public policies and the guidelines in the mental health field. It is a descriptive cross-sectional study, with both qualitative and quantitative approach, which involved the participation of 135 students and newly graduates, and courses in mental health, all related to ten OT graduation programmes in São Paulo State, Brazil. The data collection involved documentary analysis of materials provided by the programme coordinators: documental forms, Pedagogy and Policy Projects, syllabi of courses related to mental health; semistructured interviews with the professors; and questionnaire given to students and newly graduates. The documentary information was organized and the questionnaire and interview data were used, respectively, for category and thematic analysis. The results indicate that the internship in mandatory in mental health among the majority of the schools participating in the study and, in general, the sites comply with the SUS (Sistema Único de Saúde Unified Health System) requirements. It is also observed that the students and newly graduates feel relatively confident for the practice in the mental health field; they know the publics policies and understand that there is a lack between them and the reality found in the places available for their professional practice. They report to be more confident in relation to: multidisciplinary teamwork, being able to assist in general health, and plan the treatment based on a broader aspect regarding the subject s needs in his daily life. On the other hand, they feel more insecure to leading a team and managing mental health services. Professors further the remarks in regards to the challenges in training and highlight the need of approaching a more diverse and complex both theoretical and practical contents of the curriculum guidelines. Besides, they consider that the general training is the most appropriate and relevant during this stage and consider the continuing education to be a way to guarantee the necessary elements to perform professionally. It is argued that, despite of its conditions, the programmes follow the DCN-TO ans make efforts to offer a training closer to authentic practice environment in order to have a professional who can make a difference and work under the SUS guidelines. It is believed that this study may contribute for occupational therapist s understandings about practical and theoretical training in mental health and for making considerations between public health policies and professional training during undergraduation, as well as offer assistance to guideline improvements. / A instituição das Diretrizes Curriculares Nacionais do Curso de Graduação em Terapia Ocupacional (DCN-TO), ocorrida no ano de 2001, teve como uma de suas premissas a formação voltada para as políticas públicas de saúde do país. Neste mesmo período, com a criação dos serviços territoriais, a atenção em saúde mental passou a ser embasada pelos pressupostos da Reabilitação Psicossocial. Estudos nacionais recentes apontam que egressos de cursos de graduação em Terapia Ocupacional (TO) que atuam no campo da saúde mental referem que o aparato teórico e prático recebido na graduação é insuficiente para atender as demandas da prática. Este estudo teve o objetivo de compreender a realidade da formação do terapeuta ocupacional durante a graduação e a articulação desta formação com as políticas públicas brasileiras e com as diretrizes curriculares no campo da saúde mental. Trata-se de um estudo transversal e descritivo, com abordagem mista, que envolveu a participação de 135 discentes e recém-egressos e 14 docentes responsáveis pelas disciplinas obrigatórias específicas de saúde mental, todos vinculados a 10 cursos de graduação em TO do Estado de São Paulo. O procedimento de coleta de dados envolveu análise documental de materiais disponibilizados pelas coordenações de cursos: formulário documental, Projetos Políticos- Pedagógicos, ementas de disciplinas relacionadas à saúde mental; entrevistas semiestruturadas com docentes; e, ainda, aplicação de questionários junto a discentes e egressos. As informações documentais foram sistematizadas e, quanto à análise dos dados advindos dos questionários e das entrevistas foram utilizadas, respectivamente, análise categorial e temática. Os resultados apontaram que o estágio profissional em saúde mental é obrigatório na maioria das instituições participantes e, no geral, os locais para realização de práticas respondem às premissas do SUS. Verificou-se também que os discentes e egressos sentem-se relativamente seguros para a atuação no campo da saúde mental, conhecem as políticas públicas do setor e entendem que existe uma distância entre as mesmas e a realidade encontrada nos serviços disponibilizados para sua formação prática. E, em relação às competências para os quais eles apresentam maior segurança tem-se o trabalho em equipe multidisciplinar, a intervenção na promoção da saúde em geral e o planejamento de intervenção baseada em uma visão ampliada das necessidades do sujeito em seu cotidiano, por outro lado sentem-se menos seguros para liderar equipes de trabalho e atuar na gestão dos serviços de saúde mental. Os docentes avançam na reflexão acerca dos desafios nesta formação e consideram a necessidade de abordar uma diversidade e complexidade de conteúdos teóricos e práticos, dentro da grade curricular, e, considerando a formação generalista a mais adequada e pertinente para esta etapa da formação, eles vinculam a formação continuada como estratégia para garantir que o profissional adquira mais elementos necessários para a atuação no campo. Discute-se que, a despeito das particularidades, os cursos estão em consonância com as orientações das DCN-TO e que há esforços para possibilitar uma formação mais próxima do contexto real de práticas com vistas à formação de um profissional transformador da realidade dos serviços, que conheça e atue segundo as diretrizes do SUS. Considera-se que o enfoque deste estudo contribuirá para o conhecimento sobre a formação teórica e prática do terapeuta ocupacional no campo da saúde mental e para reflexões acerca da articulação entre as políticas públicas de saúde e a formação do profissional em nível de graduação, bem como para oferecer subsídios para melhorias curriculares.

Abstract Borderline personality disorder (BPD) is a common mental disorder involving a substantial decrease in functional ability, self-destructive behavior and extensive burden on the health care system. This study project aimed to create a well-structured and easily applicable treatment model for patients with severe BPD. The effectiveness of the treatment model was evaluated in a randomized controlled trial. The study group consisted of 71 patients with a mean age of 32 years. During the intervention period (1 Aug 2010 - 31 Jul 2011) 24 patients received new treatment (Community Treatment by Experts, CTBE) while 47 patients received treatment as usual (TAU). Patients in the CTBE group had 40 individual therapy sessions and 40 psychoeducational group sessions, where they were taught the key concepts of schema therapy (ST). Requirements for the therapists providing individual therapy were as follows: willingness to treat patients with BPD, commitment to weekly individual sessions with patients and commitment to participation fortnightly in a CTBE supervision consultation group, but no former psychotherapy training was required. Psychiatric treatment of the TAU group was variable. Changes in BPD symptoms, health-related quality of life, early maladaptive schemas and schema modes were measured at the beginning and at the end of the one-year intervention. At the end of the year there were 20 patients (83%) in the CTBE group and 33 patients (70%) in the TAU group. After the intervention the patients in the CTBE group had less self-destructive behavior, impulsivity, and paranoid ideation or dissociative symptoms than patients in the TAU group, which means the CTBE treatment model was able to reduce the most serious symptoms of BPD. It is possible that the reduction in self-destructive behavior of CTBE patients is linked to the fact that certain early maladaptive schemas, such as rejection, mistrust and social isolation, decreased during the intervention. Similar changes were not seen in the TAU group patients. The study showed the CTBE treatment to be more efficient than TAU treatment. In addition, the CTBE model is applicable to public mental health services using existing professionals. / Tiivistelmä Epävakaa persoonallisuus on tavallinen mielenterveyden häiriö, johon liittyy huomattavaa toimintakyvyn alenemista, itsetuhoisuutta ja runsasta terveyspalvelujen käyttöä. Tässä tutkimusprojektissa luotiin Oulun kaupungin mielenterveyspalveluihin uusi hoitomalli vaikeaoireisille epävakaasta persoonallisuudesta kärsiville potilaille. Hoitomallin tehokkuutta arvioitiin satunnaistetulla kontrolloidulla tutkimuksella. Tutkimusjoukon muodosti 71 potilasta, keski-iältään 32 vuotta. Interventiovuoden ajan (1.8.2010–31.7.2011) 24 potilasta sai uuden hoitomallin mukaista hoitoa (ns. hoitomalliryhmä) ja 47 potilasta tavanomaista psykiatrista hoitoa (ns. verrokkiryhmä). Hoitomalliryhmän potilaat kävivät vuoden aikana viikoittain yksilöhoidossa (40 käyntiä) ja psykoedukatiivisessa ryhmässä (40 istuntoa), jossa potilaille mm. opetettiin skeematerapian keskeisiä käsitteitä. Yksilöhoidon toteuttaneilta työntekijöiltä ei edellytetty psykoterapiakoulutusta. Sen sijaan heiltä edellytettiin kiinnostusta epävakaan persoonallisuuden hoitoa kohtaan sekä halua sitoutua interventiovuoden ajaksi viikoittaisiin yksilötapaamisiin ja kahden viikon välein kokoontuvaan työnohjaustyyppiseen konsultaatioryhmään. Tavanomainen psykiatrinen hoito oli vaihtelevaa. Interventiovuoden alussa ja lopussa mitattiin epävakaan persoonallisuushäiriön oireita, terveyteen liittyvää elämänlaatua sekä varhaisia haitallisia skeemoja (tunnelukkoja) ja skeemamoodeja (minätiloja). Interventiovuoden päätyttyä hoitomalliryhmässä oli jäljellä 20 potilasta (83 %) ja verrokkiryhmässä 33 potilasta (70 %). Hoitomalliryhmän potilailla oli interventiovuoden jälkeen vähemmän itsetuhoisuutta, impulsiivisuutta ja paranoidisia ajatuksia tai dissosiatiivisia oireita kuin verrokkiryhmän potilailla, eli hoitomallilla pystyttiin vähentämään kaikkein vakavimpia epävakaaseen persoonallisuushäiriöön liittyviä oireita. On mahdollista, että itsetuhoisuuden väheneminen hoitomalliryhmässä liittyy siihen, että tietyt haitalliset skeemat, kuten hylkäämisen, epäluottamuksen ja sosiaalisen eristäytymisen skeemat, lievenivät hoidon aikana. Tavanomaista psykiatrista hoitoa saaneilla potilailla ei tapahtunut vastaavia muutoksia. Tutkimusprojekti osoitti, että hoitomallin mukainen epävakaan persoonallisuuden hoito on tehokkaampaa kuin tavanomainen psykiatrinen hoito. Lisäksi hoitomalli on sovellettavissa julkisen sektorin psykiatriseen palvelujärjestelmään ja käytettävissä oleviin henkilökuntaresursseihin.