Good afternoon, ladies and gentlemen. We're about to start. I am Dinesh Bhugra, past president of the Royal College of Psychiatrists and the World Psychiatric Association. It's my great pleasure to be chairing this session. I do apologise that the programme guide says very little about the session, so you're in for lots of surprises, which means that we can do anything. So without further ado, let me introduce the speakers and the topics and we can just kick off. On my right is Professor Johannes Vanchetta from Vienna, past president of the Austrian Psychiatric Association, original APA. He is a professor of social psychiatry in the University of Vienna and his main interest has been in epidemiology and social factors. He's going to be talking a bit about comorbidity. On my left is Robert Benaventura, if I pronounce it correctly. He's the current president of the Philippine Psychiatric Society and also head of the Philippine Board for Specialist Training in Psychiatry. He's going to be talking about Philippines' response to COVID and what went on. I will come in third and I'm going to talk about geopolitical determinants of mental health, particularly as one of the running themes through the conference has been social determinants, and I want to focus on how social determinants get influenced by geographic, political, commercial determinants and what that means in terms of mental health of the populations. So without further ado, let me invite Johannes to kick off the session. After each speaker we'll have time for questions and I hope that towards the end we'll have another 10 or 15 minutes for Q&A and we hope to finish on time at 5.15. Johannes. Thank you very much for your kind introduction and for announcing my talk. Yes, I'm speaking about comorbidity of mental and physical diseases and what does it mean for service planning. I have no conflict of interest in concerning this talk and I'm starting with some epidemiological data. We know from studies in all parts of the world that in physical hospital departments we have high rates of mental disorders. So the data from a study in Austria we conducted about more than 20 years ago with a sample of 1,000 and you can see that rehabilitation departments have been nearly half of all of them had any kind of mental disorders, followed by medical departments, surgical and gynecological departments. We included all types of mental disorders. This is the reason why the frequency is so high. We also included dementia amongst the elderly and in internal and rehabilitation departments a lot of elderly people. For this reason we have very high rates in these departments. Dementia was the most common disorder followed by minor depression and substance abuse. Other data published in the last 15 years or 20 years have shown that we have an increased mortality of persons with psychiatric disorders. For example, for anorexia we have about fivefold mortality rate, for opiate dependence more than sixfold mortality rate and so on. In the last 20 years, 15 years, we learned a lot about comorbidity in schizophrenia and bipolar disorders. For example, the risk factors for cardiovascular diseases. We know that rates of obesity, diabetes, hypertension, dyslipidemia and metabolic syndromes are much higher amongst these patients as compared to the general population. These are the main reasons for increased mortality. Looking at the population level, there are some studies investigating the comorbidity between physical and psychiatric diseases. A study we have published, we have some years ago, have shown that the one-year prevalence of mental disorders was about 23%, slightly higher among women than among men. If you look on the prevalence of psychiatric disorders depending on the presence of physical illness, you can see if a person had in the last year no physical illness, the psychiatric prevalence was only 14%. If the number of physical disorders is increasing, the prevalence rate is increasing dramatically. There is a strong association between these. Looking the other way around, we have persons with psychiatric illness and persons without psychiatric illness. If we are looking on somatic illness in the last year, we can see there is a high comorbidity. The comorbidity is much higher if you have psychiatric illness. The idea that there are different groups of patients, many patients have only a psychiatric illness and the other has only physical illness, and only a small group have comorbidity is absolutely wrong. We must consider this planning services that many of our patients have two or more disorders. How shall we care for these persons? In some European countries, the idea that we should have another specialty besides psychiatry for persons who have physical psychiatric comorbidity, so-called specialists in psychosomatics. But the reality is that this covers a large majority of persons with psychiatric disorders. It is not useful to develop a separate specialty besides psychiatry. The best is if psychiatrists learn how to treat these persons. If medical doctors, specialists in general medicine, in cardiology, in dermatology, and so on, learn how to treat common mental disorders. And if you have more specialized questions, we need consultation liaison services. In the last 20 years in Europe, many large psychiatric hospitals have been closed, or the size had been decreased, and in general hospitals had been developed wards for persons with mental disorders. So in many countries of Europe, for example Italy, Finland, UK, most of psychiatric beds for psychiatric inpatients are not in psychiatric hospitals, they are in general hospitals, which include dermatology, gynecology, cardiology, and so on, and psychiatry. And this is a development, I think, which would have been very useful. The advantage, we have better somatic treatment for persons with mental illness. On the other hand, persons with physical illness have a psychiatrist very close, and for this reason we can treat these persons better, and we can provide consultation services. On the other hand, if we have psychiatry in general hospitals, the distance to the private household is shorter, and it's much easier to keep contact with the family, with friends, and so on. And finally, general hospitals are less stigmatized as compared to the old mental state hospitals. But there are disadvantages, too. Psychiatric departments in general hospitals are often smaller, usually have, in many European countries, between 40 and 80 beds, while in the old, large psychiatric hospitals, there have been 200, 300 beds. And so management is sometimes more difficult to have the infrastructure you need to treat persons with psychiatric disorders, and you need more psychiatrists and more nurses and other staff if you have small units as compared to if you have one large unit and can organize it easier. So we have challenges in service planning, and of course, comorbidity is only one of these challenges. And we must consider the other challenges when you want to plan psychiatric services. One point is reports about an increasing number of mental disorders. The discussion in Austria started about one, two years ago when we had reports about increasing numbers of persons who are in contact with psychiatric services. And these are some data we collected in the last months, and you can see between 2019 and 2022, the number of patients in several psychiatric services increased between 7, 8 percent and 23 percent. For example, in the suicide center responsible for the capital of Vienna, the number of persons who are in contact increased within four years by 23 percent. This is a clear rise which must be considered. So we looked for studies if prevalence increased in the general population. This is a study which has been published some weeks ago from the Netherlands, and they compare the years 2007-2009, these are the yellow bars, with the years 2019 and 2022. Of course, 2020, the pandemic started, and they analyzed if there's a difference between those persons included in the year 2019 before the pandemic and those included in the study during the pandemic, and they found no difference. The rise of the number of persons with mental disorders started before the pandemic, and the increase is dramatic. For example, looking on anxiety disorders, so disorders rose from 10 percent to 15 percent, mood disorders from 6 to 11 percent, substance use disorders from 5.5 to 7 percent, and all these common disorders, there was an increase from 17 percent to 26 percent. I mentioned that usually I'm doing epidemiology at the university, and if I read such a paper, first, usually I have the idea that there must be a mistake in the methods, there must be a bias. When reading this paper, I couldn't find a bias, but nevertheless, I think we need other research investigating if such increasing numbers can be found in other countries too. And one of the advantages of this study I'm presenting here is that they used research interviews, not simple questionnaires. Research interviews have much more accuracy as compared to questionnaires. And they reported that contacts with medical services because of mental health problems increased too. For example, general medical care was contacted much more often because of mental health problems in the years 2009 to 2022 as compared to 15 years earlier. Another challenge is the numbers of refugees are increasing. These are data from the United Nations Health High Commissioner on Refugees, and in the year 2012, there have been 43 million refugees worldwide increasing until 21 to 90,000, and the estimates for 2022 are 103,000. This is nearly two and a half of the numbers of 10 years earlier. It's a dramatic increase. And we know from studies of all parts of the world that persons who had to leave their country because of war, because of terrorism, and so on, have higher rates of mental disorders. These rates are dramatically higher. For example, this meta-analysis published some years ago have shown 9% of PTSD, and the general population, not refugees, this rate is about 1%. So the numbers are much, much higher as compared to non-refugees. There exist some short, simple interventions developed by psychologists, by psychiatrists, by the WHO in the last few years. This is a simple technique to reduce stress for persons who have burden because of their flight, because of war, and so on. And there exist, for example, the study of randomized controlled trials in Africa, Middle East, and Europe, overall more than 1,700 persons included, and all three studies showed that the incidence was lower. And when the studies investigated the cost-effectiveness, and it was shown to be cost-effective. I think this might be an opportunity for the future, but we mustn't forget that such interventions reduce the number of new cases. But there are, of course, new cases, and the problem doesn't disappear, it is only smaller. There exist, in the last 10 years, several psychological interventions, which are cheap and can be provided easy. Many of the studies show effects for three months, four months, six months, but we don't have data on the long run. We need more data on this. We need to train GPs how to manage persons, refugees with mental disorders, and we have to do other things, but there are many questions open. Since many years, we know that we have unmet need for treatment. These are, again, data from Austria, which are very similar to data from other countries. You can see in the line below, the left column, these are mental disorders who do not receive treatment. Nearly 60% didn't receive treatment, 20% received only psychotropics, 12% only psychotherapy, and 10% received the combination. In the last years, they had a discussion, of course, that everybody needs everything, and for this reason, we tried to analyze, asked specialists of working in this population survey, this had been psychologists and medical doctors with clinical experience in psychiatry, and we asked them how to estimate who needs which kind of intervention, because of depression, anxiety disorder, and so on, and you can see that psychotropics and psychotherapy had been most common, but often, counseling is sufficient. Some need psychiatric hospital admission, and so on, and if you compare with reality, again, we can see that more than 50% do not receive the kind of treatment of intervention they would need. We have a change in the hospital structure in the last 50 years. About 50 years ago, we had much higher numbers of psychiatric beds in all European countries, or all from Western countries. For example, in Austria, in 50 years ago, we had a rate of 1.4 beds per thousand inhabitants, and now it's 0.4. This is less than a third, and what does it mean in everyday clinical work? This is a data only for six years difference, and this data, which are from Austria, exists from other European countries, too. For example, in Austria, within six years, the number of beds had been reduced by 15%. The number of admissions to hospital increased within six years of 25%. The length of stay decreased by 30%. This means, overall, that one bed per one year was used by 50% more persons who had been admitted to the hospital. This means a major challenge for the staff working in the hospitals. Of course, hospital managers say it's a better use of hospital beds. I agree, but on the other hand, we mustn't forget this is more work for nurses and doctors, but numbers of doctors and nurses didn't increase. It's more burden, and the last few years, we have more vacant nursing positions. Some colleagues say the reason is because we increase the burden to the staff. Maybe, I don't know studies about it, but I think it's very plausible. Further, we have a shortage of psychiatrists. There had been a report of WHO that there's a shortage in low and middle income countries some years ago. In the US, a paper was published that in the year 2030, there will be 14,000 to 31,000 psychiatrists who would be needed but are not available. In several European countries, we experienced since about 20 years, Denmark, Sweden, Germany, Austria, that we don't have enough psychiatrists. We're asking neighboring countries to collect colleagues coming to us and working in our hospitals and in our outpatient services. We have ideas about the reasons, but we have not enough research to confirm these ideas about the reasons. And in some European countries, we have an additional problem. About 40 years ago, there had been plans for psychiatry reform to reduce large hospitals to build up outpatient services and so on. And at this time, many countries had support programs to get more medical students to be interested in psychiatry and learn psychiatry and to become specialists in psychiatry. This generation is retiring now and retiring in the next few years. But nowadays, the governments didn't start any support programs to become psychiatrists. And for example, these projections for Austria. Austria is overall between 1,300 and 1,400 psychiatrists. And the projections are that in the year 2030, there will be 236 positions of psychiatry missing. So we are running out and don't know how to manage these problems. World Psychiatric Association started a small study three or four years ago in Qatar to interest medical students more for psychiatry. It was a very simple intervention, which is good because it should work in all parts of the world. There have been effects, but the effects have been very small. So we need new ideas, how to increase interest in psychiatry, and I think we should have research on this field. Another challenge is trans-institutionalisation. You know, in many countries of the world, we try to reduce the number of psychiatric hospital beds. This is a plan, for example, from Switzerland, published 10 years ago, to reduce the number of beds of 0.96 per 1,000 inhabitants to 0.7 or to 0.4. In addition, there have been plans to increase the number in other services. For example, forensic psychiatry, day hospitals, homes for civilly mentally ill, but overall, the numbers are the same. So the idea to get persons with mental disorders out of psychiatry, out of institutions, works only in part. Of course, day hospital places are good because there is more autonomy for patients. Homes provide a more natural environment than hospitals, but autonomy is not living in a home, and we should look if we have other opportunities to get more people without the institutions. An approach which was discussed in the last few years is Housing First. You know, it's the idea of work rehabilitation, first place, then train. And this is the same idea to have a private household. The person who lives in this private household gets support from a social worker or a nurse and stays in this private household, while traditionally we moved people from hospitals to homes for persons with mental disorders. And very often they had not been able to come out of the services. There exist several studies with good study design for homeless civilly mentally ill, and the results are very positive. Concerning non-homeless civilly mentally ill, the number of studies is very small. This is, I think, one of the first studies in Europe, and you can see the outcome is good. The admissions to homes is much lower, there's less homelessness, forensic problems are lower, and so on. It might be that this is an opportunity for the future, but we need more research on this. So overall, we have a high physical psychiatric comorbidity, and we need appropriate services to treat these persons, to care for these persons. But we must consider the other challenges too, and they are very often much interlinked and connected, and it's not easy to consider all the problems we have, but we must look at all these problems. I think it's important to know if psychiatric disorders really increased in the last 10, 15, 20 years. If this happened, we need other strategies, I think, as we are doing now. I think we need more collaboration with other professions like nurses, like social workers, like psychologists, and with lay people too. But, of course, we need a lot more psychiatrists in many countries of the world. So just a short announcement. In September, we will have the World Congress of Psychiatry in Vienna from September 28 to October 1. The deadline for early registration is very soon. It's in about 10 days, and I'm happy if you come to Vienna and I meet you there, and thank you very much for your attention. APPLAUSE Thanks very much, Johannes. Not only for the talk, but sticking to time. We've got a few minutes for any quick questions about any points of clarification or data. Anything that's not clear? Please. Do you want to come to the mic? Thank you. Hi, thanks. I just had a question. In the US, there's a lot of talk about, or concern even, about increased utilisation of psychiatric nurse practitioners and other such providers. How is that faring in European and other world countries? Is that having an impact on those situations? How the situation is in developing countries? Increased psychiatrisation or increased criminalisation, increasing numbers in forensic... A lot of facilities are relying more on hiring non-physician psychiatric providers. Yeah. OK. The rule of non-physicians... In those areas. Yeah. Yeah. Yeah. Thank you. Of course, things changed, legislation changed. This might influence, for example, increase in forensic services. We need other staff too, like nurses, social workers and so on. But, of course, we need psychiatrists also. But I think, going back to your point, increasingly a lot of the work is being done by non-clinicians. A, because they're cheaper, and B, because there is shortage of clinicians. And what that means in reality is, on the one hand, we are psychiatrising a lot of normal human emotions. We want people to seek help. And then we can't provide that help, which increases stigma. Which then creates another problem. So I think the challenge... I mean, I've just finished chairing a commission for WPA on psychiatric education. But it is psychiatric education, but also you have to educate people at public population level, at community level, at family level, at individual level. But those have to be matched by resources. And I think that's something that the profession really needs to take head-on and see where we go with that. And we'll come back to that in further discussion. Are there any other quick questions for clarification? I'm not sure if we have really a psychiatricisation of problems. Maybe there's some areas. But people working, for example, in crisis intervention services for suicidal persons, they say it's the same type of persons who came ten years ago. But the rate of the persons, the number of persons coming is higher. So it's not a change of definition. I agree that there have been some definitions when changing from DSM-IV to DSM-V. But I'm not sure if this is the real cause of this problem. I think the challenge is really what's psychiatry for? And that is something that we need to get right. I agree. Okay, Robert, over to you. Robert is going to be talking about COVID-19 in Philippines. So, mabuhay, as we would say in the Philippines, and good afternoon, everyone. Thank you for taking the time to join us in this session. So I'm tasked to talk about emerging clinical practice patterns as a result of the COVID-19 pandemic in the Philippines, identifying and confronting the challenges in our setting. So these are my disclosures, nothing that's pertinent to the current activity, and the learning objectives. So this is Burden. Just as a recap of the timelines, as we all know, basically it all started in 2020. In January 2020, the first case of COVID-19, a 38-year-old female Chinese national from Wuhan was identified in the Philippines. And just a little over a month later, March 7th, the first local transmission of COVID-19 was confirmed. And on March 9th, the country was placed under a state of public health emergency, and so on and so forth, until March 16th, when technically the entire Luzon Island, one of the biggest islands in the world, was placed on extended community quarantine. So that meant that we could not leave the house. And we thought it was just going to be for two weeks, and then, you know, it went on for more than two years. We don't have exact statistics, but let me share some information, a couple of pieces of information. The first one was from the teleconsultations based from the National Center for Mental Health, our state mental hospital. We were very fortunate that they were able to start this crisis hotline in 2019, or a few years earlier, just before COVID-19 struck. So we were at least very lucky that it was in place when the shutdown occurred. So if you look at the comparisons in terms of the average monthly calls, average daily calls, and just focusing on monthly and daily calls, so the graphs on the left, for example, on the first graph on the left, the red bar represents what was the number of calls from May 19 to February 20, about a year before. And then during the height of the pandemic, as you can see, the number of calls more than doubled on a monthly basis, similar to the patterns that were seen as far as average daily calls were concerned in the middle graph. And finally, on the right graph, the percentage of callers due to anxiety. Well, essentially, most of the callers, about a third would be primarily due to anxiety, and it was mainly as a result of COVID-19. So it was directly related to COVID-19. Okay. There was a survey that was done early on in the pandemic out of the Philippine General Hospital, and this was a survey of almost 1,900 respondents. Most of them, these were online, and most of them were between the ages of 18 to 40. So essentially, individuals were at least technologically aware, okay? And these were the results of the survey. So almost 30% of the respondents reported moderate to severe anxiety levels. So this does not include mild levels. So moderate to severe anxiety levels. Okay. And then, sorry. Okay. And then 16.3 of the respondents rated the psychological impact of the outbreak as moderate to severe. Where does it go? Apologies again. And then 13.4% of the respondents reported moderate to severe stress levels. And then finally, 16.9% of the respondents, just let me go back, reported moderate to severe depressive symptoms. So as a result of the impact of COVID-19 on Philippine mental health care, I just want to emphasize first that the Philippines is, from an economic perspective, part of the low- and middle-income countries. So I just wanted to emphasize that our resources were already limited at that point, and that primarily, for example, like at present our total population is 110 million, and there are less than 700 board-certified psychiatrists practicing in the entire country. And most of the psychiatrists are practicing in urban areas. So remote areas would more likely not have any psychiatrists available. So the presence of COVID-19 really impacted so much as far as delivery of mental health care was concerned. This was an interesting paper that I saw a couple of years ago from Gruber and Rottenberg, because it sort of paralleled what we were doing as far as the Philippines was concerned in terms of flattening the mental health curve that we were experiencing at the time. So the steps would include, number one, reimagining mental health care. Number two, democratizing mental health care. Third is taking a proactive approach. And then finally, tracking mental health at the grassroots level. So I'll just go through this one by one and share information in terms of what we did as far as the Philippines was concerned. So of course, primarily from the perspective of reimagining mental health care, as you know, the traditional concept at the time was going to the hospital or going to the clinic to see the psychiatrist or the mental health care provider Of course, it changed in terms of how we would do that. We would still have face-to-face, but we also started to rely heavily on online consultations or tele-mental health. So one of the immediate tasks that we did was to provide guidelines as far as how to do tele-psychiatry during the global pandemic, because a lot of, well, practically all of us who were practicing as clinical psychiatrists, this was totally new, as probably a lot of you as well. So therefore, we needed to have a significant degree of guidance as far as that approach to mental health care provision was concerned. At the moment, almost all psychiatrists in the Philippines are still practicing tele-psychiatry because we found that it was very convenient for psychiatrists. Unlike other specialists like obstetricians and surgeons, they found it very challenging to do tele-consultations, but for psychiatrists, it was something of a boon for us. So we totally maximized that, and almost all accredited psychiatric training institutions practice tele-psychiatry to a significant extent. So the second step was democratizing mental health, and I think it was alluded to in the earlier lecture. So we needed to veer away from the concept of it's just the psychiatrist who is delivering mental health care, so we needed to rely also on other mental health care colleagues such as psychologists, social workers, guidance counselors, and nurses. So one of the steps that had to be done during the pandemic was to be able to train these individuals, and this included, of course, I just wanted to emphasize, and this was also mentioned earlier, non-psychiatric physicians. And one of the approaches that we did was the application of the MHGAP program from the WHO. Although, as you know, the Philippines consists of more than 7,100 islands, depending whether it's high tide or low tide, of course, so it was really a challenge to be able to provide training to the most remote areas of the country because there were mountains as well, and not all provinces would have accessible roads, so that was really very challenging. In the pictures would be an example of how MHGAP was provided, and this was, if you recall, Typhoon Haiyan a long time ago which devastated a region in the Philippines, and the MHGAP program was very helpful as far as educating or training the non-traditional mental health care providers in terms of being able to provide mental health. So this was very effective at the time, and we're fortunate that we had that experience. The network was established at the time, and we were able to reapply the network during the COVID-19 pandemic. And the third step that we took was, of course, the proactive approach because we couldn't just focus primarily on helping individuals who were developing anxiety and depression. We needed to find ways by which we can prevent that, and, of course, that would be primarily looking as far as proactive approaches. So we did our share in talking about well-being. You know, we did mindfulness lectures, lectures about mental health in the workplace and stuff like that, but one of the biggest tasks that we did as far as the Philippine Psychiatric Association is concerned and also mental health care providers was helping our first responders, OK? The physicians, for example, the three major groups that we developed training programs or at least for well-being included the Philippine Medical Association, which is the primary organisation of physicians in the Philippines, and then the Philippine College of Physicians, which is the main organisation of internists, gastroenterologists, and then the Philippine Pediatric Society. So we worked with them, developing programs for them, coming up with videos of lectures and then training manuals for them to be able to help themselves. And at certain instances, we also tried to incorporate stress management therapies as far as their training programs were concerned. And then the final approach, of course, would be the grassroots level or community-based mental health programs. In the Philippines, as I've mentioned, most psychiatrists would be in urban areas, and therefore it was really very critical to be able to go into the community and train, for example, rural health physicians and nurses and midwives, OK? Because they were at least medically trained and it was easier for them... It was easier for them to understand training as far as mental health care was concerned. The challenge, of course, was the accessibility and the resources available, but a meeting that I attended, the Committee on Health and Demography under the Philippine Senate last week, the Department of Health mentioned that they've already trained since the pandemic started... Since the lockdown started, not just the pandemic. Since the lockdown started, they've trained over about 8,000 rural health workers as far as mental health care assessment and management were concerned. There's a project that I'd like to share as far as the Philippine Psychiatric Association is concerned. We call this the Baler Project. Baler is a small town in the northeastern coast of the Philippines. From the near psychiatrist, it would be about six to eight hours by land if you drive. And that's the only way you can access it because you couldn't fly. What we did was we established a memorandum of understanding with the provincial hospital a couple of years ago and the approach primarily was because they had physicians, they had what we call rural health physicians, who were already trained in MHGAP, but the thing was they were still somewhat unsure or insecure about doing psychiatric interviews and diagnosis and applying management techniques. So our deal with them, our contract with them, was for us to go there several times a year and then conduct trainings and at the same time help them with outpatient clinics and stuff like that, which was interesting because when we started working with them, this was before the pandemic, and one of the approaches was for telephone consultation. So if the rural health physician in Baler was unsure about the diagnosis or management of a particular patient, then they can call on a psychiatrist who was based in other parts of the country. But, of course, the pandemic changed the situation and, of course, we are now hoping to be able to practice teleconsultation. That's why we're very fortunate that there's a group of psychiatrists and neurologists from various parts of northern Philippines who are able to involve themselves as far as this project is concerned because we hope to do this sort of like a pilot project that we can apply in other parts of the country as well. So other considerations, of course, would be, of course, to change the educational system, to be able to incorporate the learnings that we have in teaching medical students as far as how to approach mental health care. How do you say it? The directive from our commission on higher education now for medical schools is to teach the medical student how to be a primary care physician at the community or what we call barangay level, okay? So at the grassroots level, not someone who will practice at a high-end, technologically advanced hospital, okay? So we need to also train our future psychiatrists to be able to deal with these kinds of situations because this might not be the only time that this would happen, and that's why we also need to retrain current psychiatrists. So one of the challenges that we had was retraining the more senior members of our organization in terms of being able to do teleconsultation because, again, we don't have that great digital resources, but we try to do what we can, of course. And then finally, caregiver support and respite would be something that we would look into as well. But what would be the barriers and challenges that you would see? Of course, mentioned was resources, and then manpower. I was surprised about the decreasing number of psychiatrists in Western Europe. In the Philippines, because as mentioned earlier, I'm also chair of the specialty board of Philippine psychiatry, which is responsible for the assessment and evaluation of psychiatrists who become specialists, is that I was sharing earlier with the Philippine psychiatrists in America that before the pandemic, we would just have 20, 25 applicants for the exams. But this year, now, our exams will be on August 4. We have 45 applicants already. So the number of applicants have doubled. The number of Filipino physicians applying to be trained in psychiatry have increased as well. And one of the reasons, primarily, because of the impact of COVID, people saw, physicians saw the value as far as mental health care was concerned. So unlike before that they would consider just going into internal medicine or surgery or pediatrics or obstetrics, now psychiatry is top of mind for them as far as training is concerned. So we're very pleased about that. But still, with 110 million Filipinos, that may not be enough. So we would need more. Fortunately, the number of training institutions for psychiatry have also increased. So another barrier challenge, as we have mentioned or alluded to already, would be digital resources and other infrastructure. We hope that it would improve. And then support from government organizations, non-government organization, and private sector support. So we have so much to prepare for in what is here and what is about to come. In a meeting, I already mentioned that one of the tasks that we have was in terms of, we were fortunate in 2018, the Mental Health Act was signed into law. So we're very, very fortunate. Because when it was signed into law in 2018, the Philippines was the only country in the Asian region that did not have a formal mental health law. So in 2018, we were lucky that we had one. So at least it's facilitating the work that we do in psychiatry or mental health care in general is gaining better appreciation and acknowledgement from other sectors of society. We mentioned about resources. So substantial investment would be needed to avert mental health crisis. And that's something that we would require as well in the Philippines. And with that, I'd like to end my lecture and to thank you very much for your very kind attention. Good afternoon, everyone. Thank you. Beautiful. Any questions? Any immediate questions? And then we'll pick up some of the issues in the final bit of the panel. No? No? Please come to the mic. Oh, we had a wide range from non-psychiatric physicians nurses, midwives, and social workers. Everyone that we could invite to be trained, we did. The session is about international psychiatry. And some of the issues have already been touched upon and particularly in lines of, Johannes mentioned the refugee mental health question. Robert has talked about COVID. And I want to take a much broader view about geopolitical determinants of mental health. I got interested in the field just to understand what happens. Quite often, we have these national policies, we have these international collaborations. We look at global mental health. But the problem is that cultures are very relativist. And we know that each culture, each country, each state, each healthcare system is going to be affected by different sets of social determinants. And they affect intergenerational perspectives and they are influenced by various other factors and so on and so forth. Right. So just to remind ourselves that, mental health is indisposable to personal wellbeing, family and interpersonal relationship is the springboard of thinking and communication skills, learning, emotional growth, et cetera. And we know, and it kind of really annoys me when people talk about pandemic of mental health. Surely that's a good thing. We should be having pandemics of mental health. We should not be having pandemics of mental illnesses or mental ill health. And in some ways by talking about mental health issues and mental health concerns, we are ignoring the severity of serious mental illnesses. And what that means in practice is that we ignore serious mental illness, we ignore the normal human emotions become very psychiatrized, very medicalized. And so you can't be stressed, you have to have PTSD. You can't be having a bad day, this is depression. And what that means is that in some ways it's really good that people are aware, but it also means that the demand on professional resources increases, pressures increase and that means in, we've heard about shortages of staff. So you can't deliver services, which as I was saying earlier which contributes to further stigma and discrimination. And we know, and there's a lot of work done by Michael Marmot and his WHO commission on social determinants of health. And it's quite interesting that if you look at his original report, there was no mention of mental health. It took him a long time to realize that mental health needed to be there to try and understand. So part of the challenge really is how do we conceptualize social determinants? And we know, there was a book published by American Psychiatric Association on social determinants and Shim and colleagues remind us that social determinants is not something new. It happened in 19th century. Durkheim had identified the role of social environment on rates of suicide. And although there is substantial heritability, social determinants and stressful events cause mental illnesses, we know that. And social determinants are not independent. They are influenced by geopolitical factors. They are influenced by, and if you look at geopolitical factors, they are natural and man-made. Natural would be things like earthquakes, volcanic disruptions, tsunamis, hurricanes, typhoons, floods, droughts. And then there are man-made factors like wars and conflicts and deforestation, arson, terrorism, et cetera, which then contribute to increase in rates of migration, refugee status, asylum seeking, which then adds on to stress and high rates of psychotic disorders. And the social determinants, geopolitical factors affect social determinants, which then impact on nations, communities, families, and individuals. And we know that the geopolitical factors will lead to internal and external migration, and each wave of migration causes problems. So geopolitical determinants include political determinants, include commercial determinants, include geographical determinants, and cultural determinants, and I'll come back to each of those. And they then influence social determinants at national, regional, local levels. And within the social determinants field, people have started to talk about political factors. So social factors, cultural factors, hate individual factors, whether individuals then become ill or stay healthy. And one of the challenges for psychiatry really is that in some settings, people have forgotten the social bits, but we need to bear biopsychosocial, spiritual, anthropological models of illness, and particularly looking at cultures across. And if you're looking at truly international mental health, then we need to be thinking about those kind of cultural models. So political determinants are to do with politics, ideology, policies, which are internal and external. There are economic determinants, which are to do with wages and type of capitalism. There are commercial determinants, which are to do with, and I'll keep coming back to all of those, they're to do with fast food, multinational corporations, what their impact is. And then cultural determinants, which are perceptions of health, and geographical determinants, which is about regional and national variations. So we know that political systems affect occurrence of psychotic disorders. And I'll give you two examples in a minute. Political systems affect resources, they affect economic growth, they affect societal growth. We know that. But we never take that into account when we are trying to discuss things with the policymakers. So these have both direct and indirect influences. And one of the earlier studies in 1982 by Hupka and colleagues, looked at rates of morbid sexual jealousy across different nations. And at that time, they found that the rates of morbid sexual jealousy were almost nil in communist countries. Now you can sort of interpret it any way that you want, but there was a clear difference. And we know, and you know, the work of Hudson Bueller and colleagues in this country has shown quite categorically, that if you bring in equality in law, rates of psychotic disorders drop, particularly for LGBTQ plus populations. And that's a political decision. And then, you know, that equality in law brings out reduction in suicidality, common mental disorders, et cetera. And Dawes from Johns Hopkins has written a recent book on political determinants and it's worth a read, because he talks about systematic processes which structure relationships. It's the politics which distributes resources, administers powers, and it's how these things then contribute to health inequity. So three key political determinants are voting, who you get into power, the government and their policies. Politicians are really not interested in long-term vision. Their vision is till next election. And sometimes not even next election is kind of 18 month cycle, because they know that the next two years after that, they're going to be spending canvassing and so on and so forth. So these political determinants create social drivers, poor environmental conditions, inadequate transportation, unsafe neighborhoods, lack of healthy food options, which all then go on to affect our health and mental health. So income inequality, political conflicts, these determine population health. And again, one of the big challenges for us is to look at how political systems affect cultures. And it's been shown time and time again that egocentric cultures show higher rates of common mental disorders, but they all show high rates of divorce, crime, et cetera. Are these due to reduction in family support or are there any other factors? And that contributes to these health inequities. And this is an absolutely fascinating study by Gamil and colleagues. They showed that there was a significant increase in preterm birth, sorry, that should be preterm, not preteen, births among Latina women. The increase varied between 3.2 and 3.6% following the 2016 presidential election. And to me, that's an absolutely astonishing finding. So you can imagine what happens to those women who've had premature birth, what happens to their mental state, postnatal depression, postnatal postpartum psychosis, et cetera, and what happens to those children in the long term just because a particular election result. And authors attribute these critical gestation periods, but there are much more to say that this is much more than simple increase in numbers in period of vulnerability, has effect on brain development, subsequent sequelae, and we know. And there's a lot of evidence coming that early attachment patterns, the way you communicate with children affects brain development, brain structures, and consequently brain functioning. And that's critical social input into long-term development, et cetera. And in a review of reviews, McCartney and colleagues concluded that politics, economics, and public policy are important determinants of public health. So social democratic welfare state types and countries spending more money on public health and have lower income inequalities have better self-rated health. What more evidence do we need? And interrelationships between governance, politics, power, macroeconomic policy are really significant, and we should be looking at that together. So political ideology influences detention of patients, compulsory admissions, resources that go into forensic psychiatry or into prisons. And we know that in Italy, when Basaglia really pushed for reforms and psychiatric asylums were closed, patients moved into the community. That was a political decision. And of course, there are challenges, and as we heard from Johannes about resources, so how do we use that to get that right? And we know commercial determinants, and there are direct impact of commercial determinants on health, and there's indirect impact on mental health. So it's multinational corporations work in a very aggressive capitalist way, which affects choice of food, use of alcohol and tobacco. And we know that it took a long time, it took almost 50 years for politicians to realize that tobacco causes cancer, and certainly in the West, those things, there were much more stringent tobacco controls were introduced, so tobacco companies moved eastwards. And rates of smoking in China and India, particularly among young population, are really horrendous. And fascinatingly, I don't think it's two thirds of adults are overweight, it's about a quarter, but it's a leading cause of ill health, contributing to cancer, diabetes, hypertension, and we know that the greatest health burden then falls on communities which are poor. So these obesity related conditions then impact upon mental health. So you're more likely to become depressed, you're more likely to become anxious if you have these conditions, and therefore, in comorbid terms, you need to treat both, and as again, as we heard from Johannes, as the multinational corporations are in it for profits, let's be honest. But equally, our pensions depend upon their profits. So it's a kind of vicious circle that we need to be looking at as what that means. So they control strategies for manufacturing and distribution of products, and we know that they've been involved in political activities like lobbying, donations, misinformation, and multinationals use instrumental structure and discursive power to undermine public health policies that threaten their profits. And many corporations choose production, price setting, aggressive marketing, and young people are especially at risk of being influenced by advertisement and celebrity promotion of materials, fast food advertising, alcohol, et cetera. So there is also related to commercial determinants that are direct impact related to alcohol dependence, related to gambling. And one of the major challenges really is how do we use that to educate people? And it produces those commercial determinants, and I think what we need to bear in mind is not only the commercial determinants in the sense of what is being produced, but it's also where it's being produced, working conditions, situations in factories, pollution, transport issues related to that. And that all contributes to this geopolitical determinants. And we know, I mean, this was a chapter in a textbook of social psychiatry that I'd edited last year. Eisenberg, Wyatt, and Prince talked about that between 2000 and 2017 in the USA, drug poisoning went up by 44%. Alcohol by 40%. Suicide by 35%. And we've known about epidemic of opioids. And their argument is that in epidemiological studies which looked at different approaches while studying the relationship between capitalism, a socioeconomic system, means of production, profits, and mental ill health. So we need to be very careful looking at that because capitalism can cause alienation among workers who've lost control. They're just being used as a pair of hands without any support. The work atmosphere, work organization, work environment, and which contributes to overall satisfaction or dissatisfaction and quality of life. And O.P. Singh in an editorial in Indian Journal of Psychiatry talked about economic determinants of mental health. And it was really fascinating that in India, farmer suicides were an epidemic about eight, 10 years ago. And every time a farmer committed suicide, the federal government gave 100,000 rupees, which is about five, I don't know, $500 or something insignificant in terms of, but 100,000 rupees to each family. And guess what happened? Suicide rates went up because farmers kept saying, well, I will die, but at least my family will have some money. And something similar has been shown in Brazil where conditional direct payment then interestingly led to clear reduction. So we need to be aware what those are. And we know that there are very clear cultural determinants of mental health, which is again part of the geopolitical system. And a secondary data analysis by Andreas Merker from Zurich showed that traditional cultures such as conservatism, hierarchy, and self-mastery were negatively correlated with psychiatric diagnosis and symptoms. And I think we need to look at it much more carefully than we have. We need to do some prospective studies to look at egocentric conservative cultures versus sociocentric and not so conservative traditional, non-traditional cultures, et cetera. And are these cultural variations due to imposition of Western diagnostic categories and category fallacy as described by Arthur Kleinman? We need to be very clear. And what about cultures in transition where things are beginning to change and people are still sort of struggling to find their different explanatory models and pathways into care? Since 1930s, we have known that there are geographical determinants of mental health. There are urban-rural differences in rates of various disorders. WHO studies, International Pilot Study of Schizophrenia and determinants of severe mental disorders showed variations in rates in countries. And is it simply geographical or is it something else? So this is really fascinating stuff by Renfrew who's a psychologist and his colleagues who showed personality trait variations in geographical areas in the USA. Extroversion high in Great Plains, Midwestern and Southeastern states, lowest on the East Coast. Agreeableness more in the Midwest. So what does that tell us? That do people sort of come together because you have similar personality style or do you kind of learn from each other? And they, same group showed that resident states with high levels of wellbeing were wealthier, better educated, more tolerant, emotionally stable in comparison with states with low levels of wellbeing. And this is another fascinating study. That's a CDC data from 2009, 2.4 million people. They describe frequent mental distress. Now this is not a psychiatric diagnosis. But overall prevalence in 2.4 million people was 9.4%. But they're very clear differences. In Hawaii it was 6.4% and in Kentucky 14.4%. And the statewide variations changed over the period of the study, which related to educational status, disability, employment, marital status, et cetera. So there is a very interesting personality trait, personality, relationships, geography link that we need to start teasing out. Similar findings in Britain, people in Scotland and the North and Southwest and East of England were more agreeable. Extroverted people were concentrated in London, South and Southeast and pockets of Scotland, high levels of conscientiousness up in South of England and parts of Highlands in Scotland. So it is interesting that we need to be looking at it a bit more. And in an interesting systematic review, Crevenden and Jim Vanoss reported that the rates of schizophrenia are lower in rural areas and high in urban areas. And their argument is that it's the cognitive ability which is better in rural areas. And again, we need to do more work to try and find out if that is indeed the case. And we know that psychiatric determinants, psychiatry itself is practiced in a very cultural and social milieu at a number of levels and the social and cognitive developments of human beings occur within that framework of culture and society. And as I said earlier that we know that attachment patterns in childhood, adverse childhood experiences impact upon brain structures which impact upon brain functioning. And we need to make sense of that. And of course there are physical determinants about biology creating vulnerabilities and role of epigenetics. And then coming back to social determinants which are very much about intergenerational perspective and intergenerational difficulties and vulnerabilities like gender, sexual orientation we know affects rates of psychiatric disorders. Again, just to emphasize that this originally is a study with 33 children at the age of 15 months, structural MRIs age 10 to 11. Children with more secure attachments had larger gray matter volumes and superior temporal sulcus and gyrus. And they conclude that secure attachment affects gray matter volume in areas which are then involved in social cognitive and emotional functioning. Subsequent study with 550 sample showed disorganized infant attachment has large hippocampal volumes compared with those with organized attachment patterns. And there are changes in amygdala volume which indicates there is something that links in between this interpersonal context which are shaped by nature and quality of early caregiver infant interactions. And I'm not gonna go through adverse childhood experiences. We know that. But one of the challenges for us as clinicians is that we are focusing on medical interventions. Sometimes maybe psychological and social but never in terms of environmental factors, economic factors, political factors. How do we advocate for those things? But because, I mean I think one of the big challenges is therapeutic engagement that we have is entirely social. So when we see a patient, we recognize, we acknowledge, we understand what the patient's beliefs are, what happens to them, how that's been influenced by social and cultural values. And we work with individuals but occasionally in groups or family work or institutional. So even if we give medication or psychological treatments, these are given in that social context. The tragedy of mental health is that it's seen in isolation. It is core part of health. And health itself cannot be, should not be, must not be seen in isolation. It's related to upbringing, it's related to childhood experiences, it's related to education, related to employment, related to housing, relationships, community development, generational development, et cetera. So somehow we need to bring all these together. And one of the possibilities, however remote it might be, that we need to think about is can we convince policymakers that every policy they make has to have a health impact assessment and particularly that of mental health to try and see what it will do. And the trick working with, as an advocate with politicians is not to say that I want more resources because they'll turn around and say, everybody wants more resources. The trick is to say, what do you want to be remembered for? What you want your legacy to be? And if you go and see the politicians with the patients, they're really scared of patients. They can hear the patient's story and it makes sense. So part of the challenge for all of us is how do we advocate? How do we convey that message to politicians that mental health is important? And we need to push for coordinated, linked up, joined up thinking and policy practice. Thanks very much for listening and thank you for being here and happy to take questions now. We have 15 minutes for questions. So questions, comments to any of the speakers. Now that's a very important point because one of the challenges really is that, I'm not sure global mental health is focusing on those issues. And the other challenge for global mental health quite often is that the messages are going from the West to the East, high income countries to low income countries, rather than learning. And I was really impressed with the project that Robert was talking about, the Belar project. So why can't we learn from that? And there are really wonderful examples from really low income countries where there are no resources where we can learn and we can change our practice in a way. And yes, we can't call up Putin and say, sort it out. But what we can do is keep repeating the message to the politicians that war is not a good thing. And climate change, it's only now we've started talking and I was really pleased to see that in this program, there are sessions on climate change. I think that's absolutely vital in the next 20 years. It can't wait for another 50. And the impact that has on people's mental health. COVID was a very good example. Ebola, Zika, Middle East Respiratory Syndrome. We talk about infections, but we don't talk about the impact of those infections on people's mental health. Survivor guilt, people who recovered, people who've died, bereavement, grief reaction, loss. So I think we have a lot of work to do to convince the policymaker that you just can't see mental health by itself. Thanks very much. Robert, do you want to sort of start and then Johannes and then I'll come back to. That's one of the things that we're starting to develop right now. I mentioned about the Philippine Guidance and Counselors Association of the Philippines. There's 6,000 members in that organization, but even that is not enough for the number of students that they need to deal with. So it's rather challenging, but I'm speaking primarily from the perspective of medical students because as you know, it's very stressful and then we don't have enough individuals to help counsel them. So that's why we see a lot of burnouts and dropouts, but we try to manage as best as we can. But we don't have anything organized at the moment. We're starting to develop a program. Thank you. Yes, concerning medical students, we have the problems that many are not so much interested in mental health. Despite the fact that we increased the numbers of hours of teaching to medical students about psychiatry. 30 years ago, there have been a very small number of hours of theoretical teaching. Now we increased the theoretical teaching and increased the presence in clinical work. Despite this fact, the results are better. And I think we must think about how we can change our teaching of medical students in the future. I think that's absolutely right because we're still teaching medical students as if it was the 1950s. That's the way I was taught and therefore that's the way I'm teaching. And I've been involved in a series of studies looking at burnout in medical students in particular. And the first way we looked at 12 countries and the second way we looked at 25 countries. And the rates of burnout vary from about 65% to 95%. Now, you may argue what the definition of burnout is. But we've been using sort of standard questionnaires, online survey, and then you can also argue about accuracy of online surveys. Only people who have a grudge may be responding or all kinds of methodological issues needed to be borne in mind. And there are very clear political factors. The 95% burnout rate was reported from Hong Kong at the time of the democracy movement and demonstrations were going on. So you could understand. The other challenge has been that quite often medical students feel that they're being turned into technicians. And certainly in the UK, one of the big problems is that we use simulator and simulation for teaching and assessing. And medical students then come and say, well, I know that he's being paid to behave like this or act like this. I can't generate any empathy, which is perfectly understandable. So the challenge really is that if I had the power, I would start teaching psychiatry from day one, not in fourth year for six weeks or eight weeks or three months, regularly with every speciality, whether it's orthopedics or general surgery or infectious diseases, what's the impact on mental health? What's the impact on their functioning? And these are very bright, energetic, enthusiastic students and what are we doing to them? So again, that's a question for the profession that we really need to get our act together. And I can imagine going to the dean of a medical school and saying, this is what we need. And he or she is going to turn around and say, well, you want to keep adding to the curriculum, what do we give up? Do we need to give anything up? Why can't we just simply integrate it? Raising awareness, making sure, and you showed that the rates are going up. Whatever the reason, whether people are more aware or there's a genuine increase, we need to tackle that. And a significant proportion of psychiatric disorders are going to be treated in primary care, not in specialist care. So I like that idea of yours about medical students being trained as primary care physicians. And I think that's a model that we ought to look at. I'm not sure whether we've answered your question, but. I think you're right that we need role models. But in the UK, for example, what's happened is that for various reasons, medical students and junior doctors are working in shifts, which means that they don't get that kind of continuity of support that they ought to have, particularly at that stage where they're much more vulnerable. And yes, role models help very much. And in training, I think we need to bring in particularly in the connection of psychiatry, much more of humanities, art, sociology, anthropology to kind of make people aware. Some medical schools in the UK do, when you start medical school, you do two weeks, which is not enough, but at least it's two weeks of society and medicine. And that's where they kind of learn about social contract. What does that mean? Again, we have a long way to go, so thank you. But you can still talk to them and understand at that particular point what's going on in their lives. You may not be able to do, you're not going to change politicians' minds easily. You might do, depends upon the subject and the issue and a whole host of other factors, but the fact that a patient can feel that they can share things and you understand what it's like to be unemployed, living in an overcrowded house, not having time for yourself, not having money for food, and all you can afford is fast junk food, which is full of chemicals and it's going to, so it's that relationship. As long as they are aware that they will get a professional hearing, that you may not be able to offer solutions, you're not going to be able to write them a check and say, off you go, but the fact that you understand what it is like for them and that sense of, that relationship, which is very supportive, not critical, not damning in that sense, would help because it allows people to feel safe and they really have to feel safe when they come to us. Well, thank you all very much for sticking to the bitter or not so bitter end. It's really great to have you all here this afternoon and please join me in thanking Robert and Johannes for their wonderful contribution. Thank you.

psychiatry

mental health

geopolitical influences

Dinesh Bhugra

comorbidity

integrated service planning

tele-psychiatry

MHGAP program

community-based approaches

geopolitical determinants

policy advocacy

global mental health