Medicine (like many others) can be an extremely stressful profession. The pressures faced by clinicians are often related to ‘life and death’ situations that can lead to high levels of stress and distress. Students and trainees in a variety of allied health professions face similar pressures related to study or work environments. The practice of medicine continuously evolves and changes, and so too do the pressures. If the correct support is not accessible, this can result in burnout. Medical students are generally at a vulnerable stage in life (18–24 years) when they are more likely to develop mental health problems. A recent focus on the mental health and well-being of medical students has highlighted various worrying trends with a series of studies from around the world highlighting surprisingly high rates of stress and burnout among medical students, and fairly similar contributory factors. Despite the challenge of defining and measuring burnout, these studies indicate an urgent need for changes in methods of teaching, alongside rapid access to support. In this editorial, we make some proposals that could help the next generation of doctors to look after themselves and their patients. Medical schools have a moral and ethical obligation to ensure the well-being of their students in these stressful times.

The concept of “race” and consequently of racism is not a recent phenomenon, although it had profound effects on the lives of populations over the last several hundred years. Using slaves and indentured labor from racial groups designated to be “the others,” who was seen as inferior and thus did not deserve privileges, and who were often deprived of the right to life and basic needs as well as freedoms. Thus, creation of “the other” on the basis of physical characteristics and dehumanizing them became more prominent. Racism is significantly related to poor health, including mental health. The impact of racism in psychiatric research and clinical practice is not sufficiently investigated. Findings clearly show that the concept of “race” is genetically incorrect. Therefore, the implicit racism that underlies many established “scientific” paradigms need be changed. Furthermore, to overcome the internalized, interpersonal, and institutional racism, the impact of racism on health and on mental health must be an integral part of educational curricula, from undergraduate levels through continuing professional development, clinical work, and research. In awareness of the consequences of racism at all levels (micro, meso, and macro), recommendations for clinicians, policymakers, and researchers are worked out.

The relationship between films and psychiatry remains an ambivalent one. Mentally ill patients are often portrayed unsympathetically in a comic, villainous or inaccurate manner; and film makers often see their responsibility towards financial aspects rather than educational direction. Increasingly, films are being used for training medical students and trainees in psychiatry. Films can also be used to study therapeutic relationships between therapists and patients, especially observing transference and counter-transference. The portrayal of mental illness in films can be negative for a variety of reasons: stigma, lack of knowledge and understanding with a focus on entertaining rather than on educating. The portrayal of ECT and leucotomy and associated negative connotations have increased stigma against mental illness and even led to a reduction in the prescription of these treatments. Using films to teach is relatively recent in the UK compared with the USA, where couple therapists have used films with their patients in therapy to illustrate relationship difficulties and potential solutions. ‘Cinematherapy’ as a term has been used to work with teenagers to deal with relationship and individuation issues. An advantage of using films in teaching mental illness is that their use does not involve the confidentiality of a real patient. In addition the ‘patient’ can be seen interacting with others, giving a clearer understanding of the impact of the illness on others. Unlike clinical consultations in very narrow settings focussing on symptoms and treatment which are time limited, films can be used to learn about cultures and their embedded values.

Obtaining a level of consensus over the definition, construction and measurement of the concept of quality of life would allow for an improved degree of standardization in the assessment of clinical intervention for people with mental health problems. One of the many benefits of this standardization would be the ability to make valid and reliable comparisons between various interventions and across different groups or settings, which is of particular interest to economists. There are, however, a host of sociocultural issues that present fundamental obstacles to the satisfactory attainment of consensus over definitions and domains of quality of life. This paper considers the arguments pertinent to each of these two alternative perspectives, the economic and the sociocultural (or anthropological), and draws out the lessons that these perspectives — despite the apparent polarity that exists between them — can offer to the improved measurement of quality of life for those with mental health problems.

Migration, cultural identity and mental distress are linked. In addition, social support can provide a buffer against mental illness. Other vulnerability factors in migrants include the type of society they originate from and the type of society they settle in. Societies and cultures have been described as being individualistic or collectivist (also called ego-centric or socio-centric). Similarly, individuals are idiocentric or allocentric. When individuals migrate from one type of culture to another it is likely that, depending upon their own personality traits (along with their biopsycho social vulnerabilities), they may develop psychiatric disorders. It is possible that response to stress as a result of migration will depend upon the type of culture people migrate to. However, the cultural identity of the individuals will also determine their coping strategies. Under these circumstances, it is crucial that clinician are aware of the impact cultural identity has on the expression of distress and coping among individuals The cognitions and idioms of distress will be influenced by cultural factors. The clinicians must take into account cultural background when planning any interventions to enable a stronger therapeutic alliance.

Stigma against mental illness and the mentally ill is well known. However, stigma against psychiatrists and mental health professionals is known but not discussed widely. Public attitudes and also those of other professionals affect recruitment into psychiatry and mental health services. The reasons for this discriminatory attitude are many and often not dissimilar to those held against mentally ill individuals. In this Guidance paper we present some of the factors affecting the image of psychiatry and psychiatrists which is perceived by the public at large. We look at the portrayal of psychiatry, psychiatrists in the media and literature which may affect attitudes. We also explore potential causes and explanations and propose some strategies in dealing with negative attitudes. Reduction in negative attitudes will improve recruitment and retention in psychiatry. We recommend that national psychiatric societies and other stakeholders, including patients, their families and carers, have a major and significant role to play in dealing with stigma, discrimination and prejudice against psychiatry and psychiatrists.

With increasing globalisation it is inevitable that along with goods, people will move too. Certain psychiatric disorders are more common among some groups of migrants. It is inevitable that there may be a degree of mismatch between the cultural values and beliefs of patients in comparison with their psychiatrists. Every individual has certain cultural values and it is vital that mental health professionals are not only aware of these values but are also conscious of their own values, prejudices and both strengths and cultural weaknesses. Cultural competence is at the core of good clinical practice. Skills and knowledge about other cultures can be learnt and clinicians also need to be aware of potential sources of conflict and sources from where they can gather information and then utilise it appropriately.

Prevention of mental illness and promotion of mental health are a significant component of any clinician's clinical work load. However, often this aspect is omitted from training and service delivery due to insufficient resources and the sheer volume of clinical load. Considerable evidence confirms that prevention can significantly reduce the onset of and subsequent related burdens to mental illness, and associated personal, social and economic costs. Often prevention and promotion get confused, and further mental illness and mental health are related but distinct dimensions. Acute mental illness usually prevents positive mental health or wellbeing, yet similarly someone without mental illness can have poor mental health and poor well being. Prevention of mental illness relates closely to and can result from promotion of mental health and associated resilience.

Prevention can be categorised in multiple ways and most clinicians regularly utilise secondary and tertiary prevention. Primary prevention addresses wider determinants across whole populations. Selective prevention targets groups at higher risk of developing disorder. Secondary prevention involves early detection and intervention and corresponds to indicated prevention. This lecture summarises these challenges and the impact of mental illness, and develops the case for prevention. The risk and protective factors for mental illness and various ages of onset are presented. Interventions at different life stages are also outlined. The lecture relies on the EPA Guidance on prevention of mental ill health and promotion of mental well being using the development of UK policy as structure. Future steps will be presented within European and global context.

Good Medical Practice and Good Psychiatric Practice are key documents in the UK, indicating characteristics of a good doctor and a good psychiatrist respectively. Individual aspects of what constitutes a professional can be seen in relationship with other disciplines, team members and stakeholders. A key task of any organisation that purports to speak for the profession is to identify what these qualities are, how they are to be inculcated and developed. The Royal College of Psychiatrists, therefore, is in a unique position to do this and take it forward without guilt and shame. Leadership, teams, education, appraisals, careers and research are themes which have to be looked at. For any leadership to be successful it must have vision, strategic thinking, motivation and trust, all of which are being challenged at present. The profession of psychiatry must move from nostalgic professionalism to ‘new’ professionalism. of We as psychiatrists must ascertain our civic and fiduciary responsibilities by identifying and agreeing standards of quality of care, altruism and values of the profession identified by us and worked at with other stakeholders. The primacy of patient welfare and advocacy for our patients is critical. For our medical-moral interdependence we must be honest with ourselves as to what our strengths and weaknesses are, but also with society to declare what we can deliver in reality and what our aspirations are. Courses in ethics, humanities and human values (medical history, social sciences, literature and films) can sensitize the clinician by raising awareness and developing critical reflection.

Psychiatry is that branch of the medical profession, which deals with the origin, diagnosis, prevention, and management of mental disorders or mental illness, emotional and behavioural disturbances. Thus, a psychiatrist is a trained doctor who has received further training in the field of diagnosing and managing mental illnesses, mental disorders and emotional and behavioural disturbances. This EPA Guidance document was developed following consultation and literature searches as well as grey literature and was approved by the EPA Guidance Committee. The role and responsibilities of the psychiatrist include planning and delivering high quality services within the resources available and to advocate for the patients and the services. The European Psychiatric Association seeks to rise to the challenge of articulating these roles and responsibilities. This EPA Guidance is directed towards psychiatrists and the medical profession as a whole, towards other members of the multidisciplinary teams as well as to employers and other stakeholders such as policy makers and patients and their families.

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

Every individual is born into culture and has cultural values, norms and models integrated in their being. Cultural values affect cognitive schema and therefore our world view. Cultures determine deviance and abnormality and suggest which health care systems to be followed and what resources should be allocated to them. There is little doubt that, both in physical and mental illness, culture impacts upon presentation, development and perpetuation of symptoms. Cultural psychiatry has developed as a speciality in its own right during the last 75 years or so. Cultural competency is defined as an ability to understand and be aware of cultural factors in the therapeutic interaction between the therapist and the patient. These include awareness of social, cultural, religious factors, attitudes, behaviours, models and explanations. This should be applicable to all patients and all therapeutic interactions. Cultural competency training at its core is about good clinical practice and the clinicians. It is about an understanding of the concepts of culture and how cultures can influence human behaviour, interpretations of that behaviour and how that behaviour is evaluated. It is about the ability to understand one’s own prejudices, a willingness to identify and explore one’s own cultural base (values, beliefs and attitudes) and to identify useful and culturally appropriate strategies for working with people from diverse cultural backgrounds. The therapist must be aware of their own likes, dislikes, beliefs stereotypes, of their own identity; and must possess an ability to be neutral and open-minded, an ability to learn about other cultures and differences as well as the strengths and weaknesses of their own/other cultures.

Culture is a dynamic and complex phenomenon that can affect how vulnerable or resilient people are responding to psychiatric disease, trauma and other factors that can precipitate suicidal behavior. Some cultures glorify suicide (i.e. historically the notorious Japanese Kamikaze pilots and more recently the radicalized suicide bombers with their own interpretations of religious scripture and ideologies); others prohibit it (i.e. certain religious groups such as Islam and Catholicism).

Immigrants, particularly refugees, have long been treated as a stigmatized and socially excluded people from their destination culture. This and other issues such as poverty, acculturation stress and unemployment that immigrants may encounter can have profound effects on their mental health so much so that they may resort to tragically ending their lives with their own hands.

The ‘idioms of distress’ that immigrants use may not necessarily match diagnostic criteria and although culture is being homogenized by globalization, there are no universal models of psychotherapy or pharmacotherapy for the treatment of mental illness that may be heralded by suicidal behavior. To summarize succinctly: one size does notfit all. Mental healthcare providers need to receive training in cultural competency in order to effectively assess and treat an immigrant who may present in a crisis.

The focus of this presentation is suicidal behavior in migrant groups. We will discuss and analyse the social and cultural factors that influence suicidal behavior in this population. We will also identify the barriers to treatment and early intervention, prevention and management strategies targeted at this specific group.