The Impact of Religious Beliefs on Mental Health: A Self-Assessment Study Among Medical Students

The Dictionary of Epidemiology1 defines epidemiology as "the study of the distribution and determinants of health-related states and events." The definition given by the WHO appends to this the phrase "(including disease)."2 In both definitions, it is health, not disease, that is the focus. However, in actual practice, epidemiologic research focuses on diseases and on risk factors for disease, rather than on health and health assets. The time has come for this to change. The study of diseases and risk factors should be supplemented with a "positive epidemiology" focused on health assets and a broader range of health-related states. Neglecting positive health assets3 gives an impoverished picture of the distribution and determinants of health and disease at the population level. Exposures that elevate risk of disease are important: poor nutrition, lack of exercise, pollution, discrimination, inadequate sleep, smoking, and so forth. However, these conventional environmental, behavioral, and social risk factors are only part of the picture of the forces that shape health. Such factors often cannot provide insight as to why some individuals are resilient, managing to thrive even in adverse circumstances, whereas others are not.4,5 Increasingly rigorous research has demonstrated that a range of positive social, psychological, and environmental factors powerfully affect physical and mental health, often with effect sizes of comparable magnitude to what is observed with conventional risk factors. For example, parental warmth in childhood affects a wide range of health and well-being outcomes.5–7 Participation in religious communities, both in childhood and in adulthood, is associated with better health including reduced risk for mortality, depression, substance abuse, and suicide.8,9 In prospective studies, education and employment are reliably associated with lower likelihood of mental health problems and higher likelihood of better physical health.10–12 Marriage predicts greater longevity and lower risk of depression.13–15 These assets powerfully contribute to health and may help offset or mitigate the adverse consequences of other harmful exposures from past or present experience. Several of these assets have been identified by the important work within social epidemiology,16 although often this subdiscipline too, like epidemiology more generally, is focused on harmful risk factors. Evidence likewise indicates that positive psychological states—such as having a sense of purpose, being satisfied with life, or having a sense of optimism—are associated with good physical and mental health. These positive psychological states do not merely reflect the absence of poor mental health. Measures of psychological well-being independently predict less subsequent mental illness, controlling for baseline measures of mental illness.17 Increasing evidence has also demonstrated that psychological well-being is prospectively associated with better physical health, even after accounting for baseline health status. For example, meta-analyses of longitudinal studies have found that purpose in life and life satisfaction are each associated with reduced mortality risk (risk ratio (RR)purpose = 0.83; 95% confidence interval [CI] = 0.75, 0.91; RRlifesatisfaction=0.88; CI = 0.83, 0.94) after accounting for a broad range of confounders.18,19 Numerous large rigorous longitudinal studies have likewise indicated that optimism is associated with decreased mortality rates and reduced risk of incident cardiovascular and other chronic diseases,20–23 and progress has been made in identifying potential mechanisms including via biological alterations (e.g., healthy lipid profiles) and better health behaviors (e.g., physical activity).24–27 Many of these positive psychological states may be considered life skills, rather than traits per se, and as such are modifiable.28,29 For example, a meta-analysis of 39 randomized trials of positive psychological interventions found that these were associated with modest but important effects on subjective well-being (standardized effect size: 0.34; 95% CI = 0.22, 0.45) and depression (standardized effect size: 0.23; 95% CI = 0.09, 0.38), with associations persisting at 3- or 6-month follow-up.30 Failing to consider positive health assets—either positive psychological states or positive relational and communal factors—can impoverish our understanding of population health and trends in population health. As an example, there has been considerable recent discussion and concern over the increasing suicide rates in the United States. The US Centers for Disease Control and Prevention released a report indicating a rise in suicide rates in the United States from 10.5 per 100,000/yr in 1999 to 13.0 per 100,000/year in 2014.31 The causes for these trends are no doubt numerous. Most of the discussion has focused on harmful risk factors, such as rising prevalence of depression. Additional insight might be gained by considering the role of potential protective factors and if their prevalence is declining. One example is participation in religious community. Several rigorous longitudinal studies suggest very strong associations between attendance and lower suicide rates with effect sizes ranging from three- to six-fold reductions for those attending weekly.32,33 A recent Gallup poll indicates that over the same 15 years in which suicide rates have been rising, weekly religious service attendance declined from 43% to 36%.34 If one were to extrapolate results from a cohort study to the general US population, it would suggest that approximately 40% of the increase in suicide rates from 10.5 per 100,000/yr in 1999 to 13.0 per 100,000/yr in 2014 could be attributed to declining participation in religious communities.35 To ignore population trends and changes in these positive factors and focus only on the distribution of, and changes in, predisposing factors, is to be blind to the full sweep of forces that shape population health. Health assets and positive psychological states should be a part of our understanding of the distribution and determinants of health and disease. However, positive psychological states and good community and relationships are desired, not only, nor even principally, because of their contributions to physical health. Rather, they are also desirable in their own right. This brings us to our second point. We need a positive epidemiology that takes as its object not only disease but also health in its fullest sense. The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."36 This is a broad and expansive definition of health, one that extends beyond the health of the body, to the health or wholeness of the entire person, to a state of flourishing. The set of outcomes that might be included are potentially quite broad including not only mental and physical health but also happiness and life satisfaction, having a sense of meaning and purpose, having close relationships, and having strengths of character.37,38 These other outcomes should also arguably be studied as rigorously as we study physical health. Said another way, we should expand efforts to focus on not only positive exposures but also a broad range of positive outcomes, both positive physical health22 and psychosocial well-being.37,38 To more adequately examine numerous health and well-being outcomes, we have advocated elsewhere for an "outcome-wide" approach to epidemiology39,40 wherein, for each exposure examined, its effects on numerous subsequent outcomes are assessed simultaneously. This approach, illustrated in recent analyses,7,9,41 has the advantage of being able to identify exposures, phenomena, or potential interventions that affect not only a single health or well-being outcome, but those that have effects on many. Moreover, for exposures that have beneficial effects on some outcomes and detrimental effects on others, such designs can uncover this phenomenon and allow for a more nuanced set of public health recommendations. These outcome-wide designs, in addition to having the potential of bringing research closer to the vision of health conceived by the WHO, are also able to allow for a more rapid expansion of knowledge as evidence for numerous outcomes is included in a single study.39,40 Failure to consider a broad array of outcomes can lead to conclusions of questionable public health relevance. For example, a study published in 2017 that examined divorce as the exposure and body mass index and diet quality as outcomes concluded that "marital transitions after menopause are accompanied by modifiable health outcomes/behaviors that are more favorable for women experiencing divorce/separation than those entering a new marriage."42 The article generated news with headlines such as "Women Who Stay Single or Get Divorced Are Healthiest"43 or "Why Divorced Postmenopausal Women Are Healthier Than Those Still Married."44 Such headlines appear without due attention to the range of outcomes that might be considered as "health" and without consideration of well-documented detrimental association of divorce with depression, loneliness, lower happiness, and higher all-cause mortality,45,46 and potential adverse effects on children.47 Although there was not necessarily anything wrong scientifically with the study, and some of the issue was with the media reporting, a broader consideration of a full range of health and well-being outcomes would provide a more holistic picture. More generally, we need a positive epidemiology because people care about things beyond just physical health behaviors and physical health—they care also about being happy, having a sense of meaning and purpose, being a good person, and having good relationships. Coming to a deeper understanding of the distribution and determinants of these other positive outcomes would constitute a valuable contribution to public health and to humanity. It is remarkable how much more we know empirically about the determinants of cardiovascular disease than we do about the determinants of having a sense of meaning and purpose in life, despite purpose being a desired outcome for almost everyone (not to mention purpose's contributions to physical health18). Through epidemiologic research, we have made tremendous advances in our understanding of the determinants of physical health and disease states. It is time now to turn the same set of empirical research methods to examine other positive outcomes as well, to examine health in its fullest sense, and to do so rigorously. And this brings us to our third and final point. We need a positive epidemiology because of epidemiology's profound contribution to methodology, toward understanding causality, and toward the uncovering of determinants and mechanisms. We need an exporting of epidemiologic methods to other disciplines that study positive outcomes. Different disciplines have different strengths. The capacity and frequency with which the discipline of psychology has been able to implement randomized trials is astounding, even surpassing the already impressive work carried out in the biomedical sciences. However, certain exposures such as marriage or parental warmth cannot be randomized. In psychology, when randomized trials are not available, much of the research still relies on cross-sectional data; as a result, issues of temporality and causal ordering are left unaddressed. These designs and analyses are problematic. Cross-sectional studies can very rarely provide any evidence at all for causality. For example, marriage and happiness are correlated, but with cross-sectional data we do not know whether this is because marriage causes happiness or rather it is because happy people are more likely to subsequently become married. In fact, there is evidence for both,48 but only with longitudinal data are we able to provide evidence for causal relationships. The discipline of epidemiology has a long tradition of thinking deeply about study designs to assess etiology with observational data, and about methods and conceptual frameworks to address questions of causation.49–52 The array of observational study designs to address causation could be of benefit in other disciplines, and for outcomes beyond disease states. Conceptual frameworks such as potential outcomes49,51,52 and causal diagrams,50–52 which epidemiology has employed, would be of value in other disciplines and for other outcomes. Likewise, the methodological toolkit developed within epidemiology concerning methods for time-varying exposures,52,53 approaches to causal mediation analysis,54 a nuanced understanding of interaction and spillover effects,51,54 methods for bias analysis,51,55,56 all grounded in counterfactual theory, provide a powerful set of resources for understanding causality. These tools are beginning to be adopted within psychology and sociology,57–60 but they are not yet in widespread use. Although analyses of mediation and moderation are common in psychology, which has developed its own set of statistical tools, these statistical methods have not historically been tied to formal causal frameworks.54,60 As a result, confounding assumptions are often ignored, which can result in erroneous conclusions and severe bias.54 Epidemiology has a great deal to contribute methodologically to the study of positive outcomes, and a great deal to learn from other disciplines that have already been studying these outcomes for some time. The development of a positive epidemiology could ultimately facilitate the exporting of powerful epidemiologic methods and causal frameworks to settings in which they are very much needed, bringing insights from multiple disciplines together. Yet another methodologic strength of the discipline of epidemiology that could be leveraged to study a broad range of positive outcomes is the large multiuse cohort infrastructure. Large studies of tens of thousands of participants, followed carefully over decades, with rich data on social, demographic, and health-related variables have been the source of tremendous advances in our knowledge of the determinants of physical and mental health. By inserting into these cohort studies a variety of other positive outcomes beyond physical health, these same data resources could be leveraged to propel forward our understanding of the determinants of other aspects of well-being. To that end, we have previously proposed a brief set of items capturing "flourishing" across a range of six domains including37,38: (1) happiness and life satisfaction; (2) self-rated physical and mental health; (3) meaning and purpose; (4) character and virtue; (5) close social relationship; and (6) financial security. Two items were selected for each domain based principally on widespread use and validation in the existing well-being literature37,61; these are given in the Table. These items could be inserted in existing cohort studies to make use of the already rich data resources to better and more rigorously study numerous aspects of human well-being. Such inclusion could facilitate a rapid development and expansion of a robust positive epidemiology both in studying etiology and in surveillance and tracking of these positive outcomes. Even the tracking and surveillance of these positive outcomes would be a substantial contribution as we currently have almost no tracking of these in the United States.TABLE.: Flourishing Measure37 , 38 and QuestionsThe discipline of epidemiology has made tremendous advances in our understanding of health and disease. The discipline likewise has a great deal to contribute to the study of other positive outcomes such as happiness, purpose, character, and relationships. We need a positive epidemiology to understand the full range of health assets, and not only traditional risk factors. We need a positive epidemiology because people care about more than just physical health. We need a positive epidemiology because, both with respect to data and to methodology, the discipline has so much potential to contribute yet further to the flourishing of all humanity. ABOUT THE AUTHORS Tyler J. VanderWeele is the John L. Loeb and Frances Lehman Loeb Professor of Epidemiology at the Harvard T.H. Chan School of Public Health and Director of the Human Flourishing Program at Harvard University. His research interests concern epidemiologic methods, causal inference, psychiatric and social epidemiology, religion and health, and the determinants of well-being. Ying Chen is a Research Scientist at the Human Flourishing Program at Harvard University. She is interested in studying psychosocial assets that help promote flourishing Katelyn Long is a postdoctoral fellow at the Harvard T.H. Chan School of Public Health and the John and Daria Barry postdoctoral fellow at the Human Flourishing Program at Harvard University. Her current work focuses on determinants of well-being, group dynamics of religion on human flourishing, and the development of tradition-specific spiritual well-being measures. Eric S. Kim is a Research Scientist at the Harvard T.H. Chan School of Public Health and is part of Harvard's Human Flourishing Program and also the Lee Kum Sheung Center for Health and Happiness. His research aims to identify, understand, and intervene upon the dimensions of psychological well-being (e.g., sense of purpose in life, optimism, etc.) that reduce the risk of age-related chronic conditions. Claudia Trudel-Fitzgerald is a Research Scientist at the Lee Kum Sheung Center for Health and Happiness and in the Department of Social and Behavioral Sciences at Harvard T.H. Chan School of Public Health, and a clinical psychologist at Ordre des Psychologues du Québec. Her research interests focus on protective and detrimental psychosocial determinants of physical health, and psychological adjustment to chronic diseases. Laura D. Kubzansky is Lee Kum Kee Professor of Social and Behavioral Sciences and Codirector of the Lee Kum Sheung Center for Health and Happiness at the Harvard T.H. Chan School of Public Health. Dr. Kubzansky has published extensively on the role of psychological and social factors in health, with a particular focus on the effects of stress and emotion on heart disease and on the role of positive psychological functioning and positive aspects of the social environment in longevity and healthy aging.

HISTORICAL DEVELOPMENT OF MENTAL HEALTH SERVICES During the last three centuries, there has been major shifts in the way mentally ill are viewed and cared for all over the world. The changes during the last 50 years are most significant. From a situation of considering the "mad" as "bad" and incarceration in jails and asylums, there is now recognition of the human rights of the mentally ill. From jails and asylums, the care of the mentally ill persons has moved to the community. Another important development is the care providers. Current approach to care in the community includes, besides psychiatrists, other mental-health professionals, primary-care doctors, family members, volunteers and the ill persons. The driving forces towards these changes have been many: the recognition of the wide range of mental disorders, the high prevalence of mental disorders in the community, the availability of a variety of interventions (pharmacological and nonpharmacological), the demonstration of the effectiveness. HUMAN RESOURCES FOR HEALTH CARE There is an international focus on human resources for health care. The theme of the World Health Report 2006 (WHR 2006) was Working Together for Health. The WHR 2006 begins with the following observation: "In this decade of the 21st century, immense advances in human well-being coexist with extreme deprivation. In global health we are witnessing the benefits of new medicines and technologies. But there are unprecedented reversals. Life expectancies have collapsed in some of the poorest countries to half the level of the richest - attributable to the ravages of HIV/AIDS in parts of sub-Saharan Africa and to more than a dozen "failed states". These setbacks have been accompanied by growing fears, in rich and poor countries alike, of new infectious threats such as SARS and avian influenza and "hidden" behavioural conditions such as mental disorders (emphasis added) and domestic violence."(xv) (emphasis added). Further, the report states The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. There is no global blueprint that describes how to get there - each nation must devise its own plan. Effective workforce strategies must be matched to a country's unique situation and based on social consensus (emphasis added). (p.119) The human resources for mental health care are grossly inadequate in the developing countries, as presented by the WHO Atlas document in 2005. In the Indian context, the development of appropriate human resources for health in general is receiving serious attention. For example, the setting up of the Public Health Foundation of India in 2006 is a good example of this concern. Both authors come from a background of community mental health and experience of training and working with primary health-care doctors. The effort is to present the "world" perspective (from the World Health Report, the World Psychiatric Association (WPA) guidelines, experiences of different countries) and identify some issues relevant to undergraduate education in India. World Health Report 2001 The World Health Report 2001 makes 10 overall recommendations. The first of this is "Provide treatment in primary care." The management and treatment of mental disorders in primary care is a fundamental step which enables the largest number of people to get easier and faster access to services. It is to be recognized that many are already seeking help at this level. This not only gives better care but also cuts wastage resulting from unnecessary investigations and inappropriate and nonspecific treatments. For this to happen, however, general health personnel need to be trained in the essential skills of mental health care. Such training ensures the best use of the available knowledge for the largest number of people and makes possible the immediate application of interventions. Mental health should therefore be included in training curricula, with refresher course to improve the effectiveness of the management of mental disorders in general health services. Integration of mental health care into general health services, particularly at the primary health-care level, has many advantages. These include less stigmatization of patients and staff, as mental and behavioral disorders are being seen and managed alongside physical health problems; improved screening and treatment, in particular, and improved detection rates for patients presenting with vague somatic complaints which are related to mental and behavioral disorders; the potential for improved treatment of the physical problems of those suffering from mental illness and vice versa; and better treatment of mental aspects associated with "physical" problems. For the administrator, advantages include a shared infrastructure leading to cost-efficiency savings, the potential to provide universal coverage of mental health care and the use of community resources which can partly offset the limited availability of mental health personnel. The specific ways in which mental health should be integrated into general health care will, to a great extent, depend on the current function and status of primary-, secondary- and tertiary-care levels within countries' health systems. For integration to be successful, policy makers need to consider the following: general health staff must have the knowledge, skills and motivation to treat and manage patients suffering from mental disorders; there need to be sufficient numbers of staff with the knowledge and authority to prescribe psychotropic drugs at primary and secondary levels; basic psychotropic drugs must be available at primary and secondary levels; mental health specialists are required to provide support to, and monitor, general health-care personnel; effective referral links between primary, secondary and tertiary levels of care need to be in place; funds must be redistributed from tertiary to secondary and primary levels of care or new funds must be made available; and recoding systems need to be set up to allow for continuous monitoring, evaluation and updating of integrated activities. WORLD PSYCHIATRIC ASSOCIATION RECOMMENDATIONS In 1998, the WPA, along with the World Federation of Medical Education (WFME) through a core curriculum committee, developed detailed guidelines for the "Core Curriculum in Psychiatry for Medical Students." One of the authors (RSM) was a member of the core curriculum committee. The recommendations present the world view of the subject. The main recommendations are given below. (The full report is available from the WPA website.) That Psychiatry should occupy a major part in the medical curriculum is now generally agreed. There are three reasons for this agreement. First, the general approach of Psychiatry which stresses the unity of body and mind is important in the whole of medical practice. Secondly, skills that are learned in Psychiatry are important for all doctors: for example, the ability to form a good relationship with a patient, to assess the mental state and to impart distressing information. Thirdly, psychiatric problems are common among patients seen by doctors working in all branches of Medicine: for example, it is known that among outpatients attending specialist clinics, about 15% of those given a diagnosis have an associated psychiatric disorder; and an average of 20-30% of those given no medical diagnosis have a psychiatric disorder. Psychiatric disorders are even more frequent among patients attending general practice. Therefore, all future doctors must know about these psychiatric problems, not only because they are common but also because their management involves much medical time and resources and gives rise to many serious incidents. THE PROPOSED CURRICULUM The core component in Psychiatry in the curriculum described in the WPA/WFME Report is the minimum that is required by medical students who, after qualification, will enter further training whether they are to work as specialists or in primary care. In many countries, doctors who have chosen a career in primary care (general practice) receive a further period of training after graduation; and in most of these countries, this training extends their psychiatric skills. In countries with no formal training for primary care doctors (general practitioners), the teaching in Psychiatry described in this report needs to be supplemented by a module containing the additional material that is essential for management of the psychiatric morbidity encountered in general practice. This module will need to be developed locally to take account of the special circumstances of practice in the country. The report describes the minimum requirements in Psychiatry for medical students who will enter further training, whether they are to work as specialists or in primary care. ATTITUDE OBJECTIVES Since most students will not enter Psychiatry, the acquisition of appropriate attitudes is of primary importance. It is important that the objective of imparting these attitudes is in the teacher's mind throughout his/her interaction with students. Most of the attitudes to be acquired while learning Psychiatry do not differ from those needed to practice the rest of Medicine. The extent to which these attitudes are emphasized to students in the Psychiatry program, rather than during the periods for other subjects, will vary from one medical school to another. However, each school should have a clear plan that ensures that the necessary attitudes have been acquired by the time the students graduate. It is important that students develop appropriate attitudes towards Psychiatry as a medical discipline. These attitudes will be encouraged, particularly during the teaching of Psychiatry, but it is important that they are not negated during the teaching of other subjects. It is important that attitudes are not merely expressed verbally by students but are also internalized, directing how students respond to patients and their colleagues. Each of the attitudes listed below should be translated into corresponding action. Attitudes concerned with medical practice generally Students should recognize that the profession of Medicine requires lifelong learning and show capacity for critical thinking and constructive self-criticism; be able to tolerate uncertainty and be open-minded to the views of others and be able to work constructively with other health professionals. Attitudes towards patients and their families Students should respect patients and understand their feelings; recognize the necessity of good doctor-patient relationships; appreciate the value of the developmental approach to clinical problems, emphasizing the stages of the life cycle and longitudinal perspective of illness; recognize the importance of the family and the wider environment of the patient and attitudes towards Psychiatry as a medical discipline Students should recognize the value of Psychiatry as a medical discipline; integrate humanistic, scientific and technological aspects of knowledge of Psychiatry and recognize the importance of the promotion of mental health and the prevention of psychiatric disorders. KNOWLEDGE OBJECTIVES The knowledge objectives of Psychiatry include psychiatric symptoms and syndromes; psychological aspects of medical disorders ("psychological medicine"); and psychosocial issues, including stigma. Psychiatric symptoms and syndromes and their treatment are to be taught and learned in the context of an integrated biological, psychological and social approach. Knowledge objectives can be formulated in broad terms or as a detailed curriculum. A detailed list may be important not only to guide teachers and students but also to indicate to the deans and curriculum committees of the medical school, the substantial factual basis of Psychiatry and the resources needed to teach this. Whatever level of detail is chosen concerning each individual disorder, collectively these should provide opportunities to (a) illustrate the approach to etiology in psychiatry; (ii) discuss attitude objectives and "teaching of skills" objectives; (iii) provide instruction concerning action that should be taken. SKILLS OBJECTIVES The skills required by medical students range from those with which they need only be familiar (in the sense of being aware that they are practiced by others, e.g., dynamic psychotherapy) to those skills which students are expected to utilize competently themselves. Many of the skills students learn in Psychiatry overlap with those learnt in the other branches of Medicine. The stage in the curriculum at which the various skills should be learnt is a matter for the curriculum committee of the medical school to decide. Skills to be acquired include the following: Doctor-patient interpersonal skills include the skills of "active listening"; empathy; nonverbal communication; opening, controlling and closing an interview. Information gathering skills include taking of the history of patient's complaints and a life history; carrying out a physical examination, taught also in other parts of the curriculum; these also includes skills necessary to assess the functioning of the patient's family and the family's ability to contribute to the patient's care. Information-evaluation skills include selecting the crucial pieces of information for making a diagnostic formulation and undertaking a differential diagnosis, making a personality assessment, evaluating the role of personal and social factors in the patient's behavior, formulating a plan of management which includes the points at which referral to a specialist will be appropriate. Information-giving skills include passing information to patients to promote health, explaining the implications of a diagnosis and informing patients about the beneficial and potential adverse effects of treatment. Reporting skills include reporting verbally or in writing to medical colleagues; lay people, including the relatives of patients, nonmedical agencies involved in the care of patients and promoting public education. Treatment skills include promotion of compliance with prescribed treatment, basic prescribing skills for the psychiatric disorders commonly encountered by nonpsychiatrists, recognizing adverse effects of treatment and distinguishing them from symptoms of illness. GUIDELINES FOR TEACHING AND LEARNING OF PSYCHIATRY Learning should self-directed, problem-based learning, with locally produced teaching aids along with exposure to a range of patients in different settings; and integrated psychiatric teaching and learning in the curriculum. Assessment Teaching methods should be evaluated by students, thus helping individual teachers to improve their performance and to upgrade the teaching programs as a whole. A distinction is to be made between two types of assessments. Formative assessment is designed to give feedback to the student about his progress as he proceeds. Summative assessment is carried out at the end of the courses for purposes of grading. Both teachers and students should evaluate each course; the latter assessments are particularly valuable. The training of teachers It is important that teaching is recognized as an important activity within the medical school. Also, the financial rewards for teaching should be commensurate with those for clinical work if teachers are to be encouraged and retained. Teaching staff are required to have an interest in teaching and have to realize that they require to be trained for their role as teachers. It is thus important that account is taken of interest in teaching when teaching staff are appointed. University departments should give high priority to teacher training, within the medical school, so that staff have educational expertise as well as clinical and research competence. There should be an educational development program to extend all teachers' understanding of the teaching-learning process, and it should be updated regularly. Educational resources should be provided: educational resource persons, educational literature and regular seminars and workshops. The teachers of Psychiatry should participate in the educational committee in the medical school responsible for the curriculum as a whole. ADDITIONAL TEACHING FOR PRIMARY HEALTH CARE In developed countries medical students graduate as generic doctors, who can enter general practice only after further training. In other countries students can work in general practice as soon as they qualify fully without this additional training in general practice. In the latter countries medical students need to receive additional teaching in Psychiatry during the medical study period, since psychiatric disorders form such a large part of the work of primary-care doctors. This additional psychiatric training in developing countries should extend across the medical curriculum as a whole. It should also continue, after graduation, as part of in-service training and continuing medical education (CME). The teachers in the countries concerned will be able to decide the necessary content of this additional preparation for general practice responsibility directly after qualification. In addition to the knowledge content, the skills needed to diagnose psychiatric problems within a system appropriate for primary care will be important, as also the skills needed for treatments used most often by general practitioners and the knowledge of when to refer to specialist services. Attitudes that will promote mental health and reduce stigma have also to be acquired. A substantial part of this additional teaching should take place in the community settings in which students are likely to work when qualified, and teamwork skills necessary for the doctor to do his work in conjunction with nonmedical staff are critically important. The international classification of diseases (ICD) classification for primary care is a useful guide to the additional teaching needed for primary care. Time and resources It is an important responsibility of psychiatric teachers to convince the medical faculty of the value of Psychiatry in the general medical curriculum. The case is made by (a) the frequency of psychiatric problems in the general practice of medicine, (b) the substantial factual basis of the subject and (c) the need to teach communication skills. When this importance has been accepted, the time needed to teach the subjects will follow. Exact figures about the amount of teaching hours that are required for the core curriculum depend in part on the amount of conjoined teaching with other departments and the extent of teaching of communication skills during other parts of the medical curriculum. The amount of time spent in the Psychiatry department will also depend on the other opportunities for teaching behavioral science and psychosocial aspects of Medicine in the curriculum as a whole. Corresponding resources need to be provided for this teaching. In addition to this full-time study, two other periods of teaching are essential. First, opportunities to teach Psychiatry are required during other clinical attachments, especially in medicine, surgery and general practice attachments. Secondly, an adequate proportion of time allocated for lectures and seminars in the curriculum should be allocated to Psychiatry and mental-health issues. Such teaching should be scheduled at several times in the curriculum, selected by the Teaching and Learning Committee of the medical school, according to the opportunities available and the skills of the teachers. With these provisos in mind, a period of eight weeks is required to teach Psychiatry; however, some of this teaching can be outside the single block of a psychiatry attachment, though the latter should never be less than four weeks. Corresponding resources need to be allocated to provide adequate teaching and learning during this period. The timing of the full-time attachment within the course is generally best in the second clinical provided that some additional time for teaching is allocated in the first and In the are taught in the first of undergraduate During the first two there are about hours of teaching in various psychosocial In the hours are to teaching of In the there is a full-time of weeks of Psychiatry to weeks each for and and weeks for Medicine and In the teaching of mental disorders in and was well in During the it acquired the status of a major clinical to place after and Medicine and of and and there are hours of Psychiatry teaching in a about of the It is a major clinical discipline with a at the end of the In Psychiatry its place in medical education in the However, it through major changes in the following the Medical recommendations in medical which the importance of and Psychiatry in medical teaching and practice. hours are to the behavioral science course during basic medical science teaching. During the clinical students first learn skills and psychiatry a during the weeks and a full-time Psychiatry for This is by a as in other subjects. There is a in on the teaching of Psychiatry since the of a new curriculum in the Psychiatric aspects of various clinical disorders are from the first by courses in Psychiatry and Most of the clinical teaching place in the and years of the course and of seminars and Students are provided the to develop skills in and are required to in detail case as well as a on the end of they are The teaching involves hours personal In the last three many countries have medical their provide for a substantial time for the teaching of Psychiatry, to inadequate resources and of trained the courses are not regularly. Most are is In the second has there is a for hours of teaching of during the first two years of the medical by a in Psychiatry during the and to of staff, this has been to only weeks. However, it one of the major subjects taught and in the the others being and and Medicine. The broad of the course are that students should learn the importance of psychological factors in social and clinical context, diagnose psychiatric illness and be able to give at primary care to serious conditions such as and mental The specific objectives are to students to recognize major psychiatric disorders in the community and be able to treat some of them and refer others to the appropriate (ii) to with psychiatric and (iii) to understand the role of psychological factors in physical disorders. and have the of Psychiatry undergraduate Psychiatry curriculum and made Psychiatry a subject for THE since the time of Committee in many committees and forces have emphasized the importance of in the undergraduate Psychiatry teaching by the amount of training in Psychiatry, (ii) making Psychiatry an subject for teaching and and (iii) the Psychiatry curriculum at the undergraduate level. It is not a that even in the 21st century, as many as of medical in India do not have departments of The exposure of medical students to mental disorders is limited to some to the mental but conditions there in among medical students rather than developing their interest in mental-health problems. the prescribed by the Medical of India as on only lectures to Psychiatry and a of in Psychiatry is taught as an discipline of though it has an curriculum This is in of recommendations of various including one by the Medical of India to Psychiatry a subject with of In the following are required on an the curriculum and the of with the time allocated to Psychiatry there has been a need of social and behavioral in the training of medical to them more aware and and develop a in primary-care setting have that as many as of patients health for a mental-health practitioners are already the of mental-health problems. However, to their effectiveness in and common mental and behavioral health problems in the community, including screening and for and other they must be provided training at the undergraduate level with frequent refresher courses as part of continuing medical education training curriculum should also include application of psychosocial in the of and policy development and research teachers of has been the changes in knowledge and Medical have such a changes in the content as well as of its This may a on the teachers who, in a Indian medical may already be with high clinical and must be involved in to their teaching skills by application of and other of information in mental-health systems are major in many by the development of has been integrated into the overall health There is an that of community mental-health care that are not on the specialist be more There is now from the effectiveness of such However, most of the research to has been in the developed countries is needed in the developing countries to this and guide in mental-health care. It without that for this to at and level, we need to the undergraduate teaching of Psychiatry, a to the essential mental-health care. It is clear that the mental-health needs of this country. there has been a for in countries and leading to regular of trained from India to these there will a between and of within the country. India has to with its mental-health it has to develop of care as in other countries, including developed Many international World Federation of Medical Education and World Psychiatric Association have developed a core curriculum in Psychiatry that can be used as a by various countries for developing their own curriculum. Indian Psychiatric must take in this to about necessary changes in psychiatric teaching at the medical of India level. The benefits of the psychiatric component in undergraduate medical education extend the primary objective of future doctors with better psychiatric considering the that trained doctors are every in India who do in mental-health needs of the country.

Background: Health-care workers (HCWs) in India have been heavily impacted by the COVID-19 pandemic, facing significant psychological distress due to their challenging work, exposure to the virus, and isolation. This study examines the emotional states and coping strategies of HCWs and the potential effects of religious coping mechanisms on their mental health. Aim: To explore the emotional state, coping strategies, and impact of religious beliefs on the mental health of junior doctors in a COVID-19-designated tertiary care hospital in Mysore. Methods: The cross-sectional survey-based observational study included residents and house surgeons working in COVID-19 wards. Sociodemographic data along with their emotional state and coping strategies were assessed using Depression, Anxiety, and Stress Scale-21 (DASS-21), Brief COPE Inventory, and the Brief Religion COPE. Chi-square test and Pearson’s correlation were used to evaluate the relationship between variables. Results: Majority (57.2%) of the participants were between 21 and 25 years and of male gender (61.6%), with Hinduism being the most prevalent religious affiliation (88.4%). Most (71.7%) tested positive for COVID-19. A significant prevalence of stress, anxiety, and depression among HCWs. Significant associations were found between stress, anxiety, and factors such as living alone, working in emergency care, substance use, and associations between religious coping and emotional status. Conclusion: The study highlighted the psychological distress faced by HCWs during the COVID-19 pandemic and proposes that religious coping techniques may help their mental health amid emergencies. Promoting an integrated strategy that incorporates psychological and religious coping mechanisms may improve health-care personnel’s overall resilience and mental well-being in the face of future challenges.

Mental health and clinical education.

To examine the prevalence of religious beliefs and practices among medically ill hospitalized older adults and relate them to social, psychological and health characteristics. Consecutive patients age 60 or over admitted to the general medicine cardiology and neurology services of Duke University Medical Center were evaluated for participation in a depression study. As part of the evaluation, information on religious affiliation, religious attendance, private religious activities, intrinsic religiosity and religious coping was collected. Demographic, social, psychological and physical health characteristics were also assessed. Bivariate and multivariate correlates of religious belief and activity were examined using Pearson correlation and linear regression. Of the 542 patients evaluated, detailed information on religious beliefs and behaviors was collected on 455 cognitively unimpaired patients. Over one-half (53.4%) of the sample reported attending religious services once per week or more often; 58.7% prayed or studied the Bible daily or more often; over 85% of patients held intrinsic religious attitudes; and over 40% spontaneously reported that their religious faith was the most important factor that enabled them to cope. Religious variables were consistently and independently related to race (Black), lower education, higher social support and greater life stressors, and religious attendance was associated with less medical illness burden. Religious attendance was also related to lower depressive symptoms, although the association weakened when other covariates were controlled. Religious practices, attitudes and coping behaviors are prevalent among hospitalized medically ill older adults and are related to social, psychological and physical health outcomes. Implications for clinical practice are discussed.

Nurses suffering in silence: Addressing the stigma of mental health in nursing and healthcare.

BackgroundSomatization has gained recognition for its potential impact on medical students’ quality of life and career longevity, who function in a high-stress environment and frequently have poor mental health, but somatization is much less researched among other health profession students who strive to excel in the same environments. Both mental and physical health issues predict leaving a career in healthcare. The aims of this scoping review were to describe and characterize somatic symptoms related to mental health in medical, dental, veterinary, nursing, and physical therapy students; define the outcome measures of somatization which were used; and document the existing evidence for interventions to prevent or treat somatization in these populations.MethodsDeveloped in alignment with PRISMA-ScR guidelines, a comprehensive search was performed with 17 databases, bibliographic searching, and hand- searching, with eligible primary studies having medical, dental, veterinary, nursing, or physical therapy students, at least one measure of somatization or a statistical analysis of separate mental and physical health measures, written in or translated into English. Data charting was performed by a trained researcher and two authors reviewed each article.ResultsSeventy-three articles met inclusion criteria, inclusive of 51 medical, 14 nursing, seven dental, three veterinary, and zero physical therapy students; and two studies had heterogeneous populations. Studies represented data from 26,200 students from 29 countries. The prevalence of somatization ranged from 5.7% to 85.2% with a weighted average of 34.4%. Commonly reported somatic symptoms were insomnia, temporomandibular disorder, and musculoskeletal pain. Seventeen studies included an intervention aimed at improving somatization or associated mental and physical health outcomes. Twenty different direct somatization outcome measures were used, and we review them based on validity and reliability.ConclusionsSomatic symptoms were highly prevalent in all assessed health professions and primary articles reported them to be strongly correlated with mental distress. Further research is necessary, particularly in the U.S., which now claims just five primary articles in the past three decades. Research on non- medical health profession students is particularly lacking, as are controlled trials and research examining the effects of somatic symptoms of stress on long-term quality of life and career attrition from the healthcare field.

The aim of this paper is to determine the relationship between cope, in particular religious coping and the general mental health assessment of one's own mental health, depending on involvement in religious practices. The study involved 135 members of the Catholic Church (112 women and 23 men), including 60 practicing believer and 75 non-practicing. The Brief R Cope, Mini Cope and GHQ-30 were used. The groups did not differ in the assessment of their own mental health and negative religious coping with stress, but only in the group of non-practitioners a significant correlation between these dimensions was observed.Key words: coping, mental health, religious coping

Introduction The term "volunteering" refers to any endeavor in which one's time is devoted voluntarily to the benefit of another individual, group, or organization, and without the expectation of receiving compensation. Several studies have discovered that engagement in volunteer work is substantially predictive of improved mental and physical health, self-esteem, diminished depressive symptoms, and psychological distress, in addition to having a positive correlation with mental well-being. Aim The objective of this study was to investigate the correlation between medical student participation in volunteer work and their mental well-being. Subject and methods A cross-sectional survey was carried out in Riyadh, Saudi Arabia, involving medical students enrolled in Princess Nourah bint Abdulrahman University and Imam Mohammad Ibn Saud Islamic University, both of which are government institutions, as well as Almarefah College, a private medical school. The students were provided with a self-administered questionnaire. Sociodemographic information, prior volunteer experience, and an evaluation of the mental health status of medical students are all components of the questionnaire. Results A total of 827 medical students participated; 798 (96.5%) of them fell between 18 years and 25 years and only 29 (3.5%) were between 25 years and40 years. Themales accountedfor 594 students (71.8%) and girls accounted for 233 students (28.2%). Among the students, 387 (46.8%) fell within the age range of 21 to 22 years, and 401 (48.5%) had a prior engagement in voluntary activities at school or college. Significant factors that influence participation in volunteering activities consist of attending a governmental institution, 616 students (74.5%); maintaining a grade point average (GPA) ranging from 2.75 to 3.74, 337 students (40.7%); and expressing a preference for participating in medical-related endeavors, 455 students (55%). There is no statistically significant correlation between medical students' engagement in volunteering activities and their mental health state (p>0.05). Conclusion A significant proportion of medical students actively engaged in volunteer work.Contrary to earlier findings, this study establishes that there is no correlation between engaging in volunteer work and the mental health conditions of medical students. Additional longitudinal studies are necessary to establish the correlation between engagement in volunteer work and the mental health of medical students.

Religious Barriers to Mental Healthcare

Global pandemic perspectives: public health, mental health, and lessons for the future

Une etude des sels nutritifs dans l'ocean est menee sur deux plans. L'un, est la modelisation de leur regeneration et de leur melange entre les masses d'eau suivant des horizons isopycnaux ; l'autre est l'analyse et l'acquisition de nouvelles donnees. Un lien tres etroit entre les sels nutritifs et l'oxygene d'une part et l'activite biologique d'autre part, caracterise par les rapports biochimiques P/N/-O2 = 1/16/138, a ete defini par Redfield (1934) et Redfield et al. (1963). Tout recemment Takahashi et al. (1985) et Broecker et al. (1985) ont propose des valeurs differentes des rapports de P/N/-O2 = 1/17/175 pour l'ocean mondial. Cette suggestion est etudiee d'une facon critique. L'etude de ces rapports est menee a l'aide d'une analyse isopycnale detaillee, a plusieurs profondeurs de la colonne d'eau de mer : suivant 4 niveaux dans les oceans Atlantique et Indien et suivant 5 niveaux dans l'Ocean Pacifique. Les donnees TTO ont ete selectionnees pour l'etude du Bassin Nord Atlantique et les donnees Geosecs pour les autres domaines consideres. On montre que le rapport P/-O2 decroit systematiquement en fonction de la profondeur d'une valeur de 160-200 en surface a une valeur de l'ordre de 108-127 en profondeur. L rapport N/-O2, qui semble altere par la denitrification dans le Pacifique Nord et equatorial, est constant geographiquement et dans la colonne d'eau. Le rapport d'abondance N/P decroit systematiquement avec la profondeur dans tous les domaines explores. Ces resultats pourraient etre expliques par un recyclage plus lent et plus en profondeur du phosphore par rapport a celui de l'azote. L'analyse automatisee des sels nutritifs a ete amelioree par une saisie et un depouillement en ligne par microordinateur pendant le programme Indigo dans l'Ocean Indien. De nouvelles donnees ont ete obtenues, d'une reproductibilite meilleure que le pourcent pour les nitrates et la silice. Les donnees Indigo, apres calibration, sont tres coherentes avec les donnees Geosecs dans l'Ocean Indien et confirment les resultats de l'analyse isopycnale dans cet ocean. Dans le bassin de Somalie, ces donnees tracent une remontee locale d'eau avec un flux estime a 7. 5 10⁶ m3/s. Ce resultat est en bon accord avec les descriptions dynamiques des courants dans la region et avec les donnees de traceurs transitoires (freons).

Heart rate variability (HRV) is the variation between consecutive heart beats over time. Increased HRV is positively correlated with better overall cardiac health. There are many lifestyle and biological factors that affect HRV. Research has examined the effects of chanting, reading holy texts, or praying on HRV, however, there has been little research done on how religion affects HRV. The purpose of this study is to determine whether there is a correlation between levels of religious beliefs and practice and HRV. Inter‐ and intra‐religious beliefs and levels of practice were measured using a scale from 1 to 5. HRVs were generated using an HRV analysis program (LabChart, ADInstruments) from a lead I electrocardiogram (EKG), measuring from one R wave to the next R wave (R‐R). EKGs, measuring 9 time‐domain measurements of HRV, were performed on 67 participants. T‐tests and Bonferroni analyses were performed on the data to determine significance. Data was analyzed from participants identifying as members of 4 different religious traditions: atheist, Catholic, non‐denominational Christian, and Jewish. There is a significant difference (p=0.03, n=10) in SDRR (std dev of R‐R time) of Catholics with different levels of religious practice, but not atheists (p=0.5, n=15), Christians (p=0.6, n=17), or Jews (p=0.7, n=11). Similarly, there is a significant difference (p=0.006, n=15) in SDRR of atheists with different levels of religious beliefs, but not Catholics (p=0.4,n=10), Christians (p=0.7, n=17), or Jews (p=0.2, n=11). The data supports significant differences in HRV between members of the same religious traditions having differing levels of practice, however the cause of this affect remains unknown.

Prevalence and influencing factors of anxiety in medical students during the COVID-19 pandemic

Suicide is a devastating public health problem, and research indicates that people with prior attempts are at the greatest risk of completing suicide, followed by persons with depression and other major mental and substance use conditions. Because there has been little direct input from individuals with serious mental illness and a history of suicidal behavior concerning suicide prevention efforts, this study examined how this population copes with suicidal thoughts. Participants in 14 regional consumer-run Hope Dialogues in New York State (N=198) wrote up to five strategies they use to deal with suicidal thoughts. Strategies were classified according to grounded theory. First responses included spirituality, talking to someone, positive thinking, using the mental health system, considering consequences of suicide to family and friends, using peer supports, and doing something pleasurable. Although a majority reported that more formal therapeutic supports were available, only 12% indicated that they considered the mental health system a frontline strategy. Instead, respondents more frequently relied on family, friends, peers, and faith as sources of hope and support. Consumers' reliance on formal therapeutic supports and support from peers and family suggests that education and support for dealing with individuals in despair and crisis should be targeted to the social networks of this high-risk population. The disparity between availability of formal mental health services and reliance on them when consumers are suicidal suggests that suicide prevention efforts should evaluate whether they are effectively engaging high-risk populations as they struggle to cope with despair.