Innovations in global mental health have focused on addressing the ‘supply side’ barriers to reduce the treatment gap and, in doing so, have redefined three core assumptions regarding mental health care, namely, what comprises a mental health care intervention, who is a mental health care provider and what is a mental health care setting. However, such innovations alone will not reduce the treatment gap because of the gap between the understanding of mental disorder that mental health specialists use, best illustrated through the diagnostic systems and the epidemiological instruments arising from them, and how the rest of the world conceptualises psychological suffering. It is this ‘credibility’ gap that needs to be bridged in three key ways: first, to distinguish mental disorders that could benefit from biomedical interventions from milder distress states; to offer interventions for distress states mainly through low intensity psychosocial interventions delivered outside the formal health care system; and to base the descriptions of diagnostic categories on the patterns of phenomena observed in general populations, rather than those observed in specialist settings.

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This special, extra issue of Intervention marks the occasion of the retirement of Joop T.V.M. de Jong as a professor of cultural and global mental health at the VU University of Amsterdam. The editors of this issue are (former) PhD students and colleagues of Joop de Jong, who have been inspired by his trailblazing work. Motivated by his role in shaping the field of mental health and psychosocial support in conflict affected settings, this issue focuses on new areas of interest in research and practice that may shape the field's future. The eight articles in this special issue, while diverse, highlight major drivers of future progress for global mental health: integrating local knowledge and experiences within the larger global discourse; using multidisciplinary perspectives derived from the clinical sciences, social science and culturally informed epidemiology; attention to risk factors and disorders beyond trauma exposure and posttraumatic stress disorder; using health systems approaches; and attention to dissemination and implementation science in global mental health. The collection of papers in this issue presents new frontiers for mental health and psychosocial wellbeing in low income and conflict affected settings, and, together, point towards a potential future agenda for research and implementation of exciting new ideas to support mental health of populations affected by armed conflict and chronic adversity.

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In this article, we suggest guidelines that should be followed in order to create a culturally sensitive cognitive behavioural therapy among refugees and in global contexts more generally, so as to maximise efficacy and effectiveness. These guidelines can be followed to design culturally sensitive cognitive behavioural therapy studies, or what might be called ‘contextually sensitive cognitive behavioural therapy’, among refugees or other cultural groups in a given global location, and the guidelines can be used to evaluate such studies. Some examples of these guidelines are culturally appropriate framing of cognitive behavioural therapy techniques, assessing and addressing key local complaints (e.g. somatic symptoms, spirit possession and syndromes such as ‘thinking a lot’) and catastrophic cognitions about those complaints, and incorporating into treatment key local sources of recovery and resilience.

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Complex situations following war and natural disasters have a psychosocial impact not only on the individual, but also their family, community and the larger society. Fundamental changes in the functioning of the family and community can be observed as a result of these impacts. At the family level, the dynamics of single parent families, lack of trust amongmembers, changes in significant relationships and child rearing practices are seen. Communities tend to be more dependent, passive, silent, without leadership, mistrustful and suspicious. Additional adverse effects include the breakdown of traditional structures, institutions and familiar ways of life, and deterioration in social norms, ethics and loss of social capital. Collective trauma can be studied using sophisticated multilevel statistical analysis, with social capital as a marker. A variety of community level interventions have been tried, though a scientifically robust evidence base for their effectiveness has yet to be established. This article advocates that post disaster relief, rehabilitation and development programmes need to address the problem of collective trauma, particularly using integrated holistic approaches.

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We have long outgrown the capacity of the accepted clinical models of trauma, and a paradigm shift in our thinking is long overdue. The data on traumatic stress were posited from a certain cognitive-behavioural viewpoint, with particular emotional components based almost in their entirety on western, mostly white individuals seeking treatment for posttraumatic stress disorder, and focusing on that time frame. As such, mechanisms such as fear and emotional conditioning theory and the ways traumas are encoded in memory only partially explain trauma response. Conservation of resources theory posits that severe trauma responses occur when personal, social or material resources, which are key to the self, survival and social attachments, are lost severely and rapidly. These resources tend to aggregate or fail to aggregate in what conservation of resources theory terms ‘resource caravans’; they do not exist in isolation. Because resource caravans are created and sustained within the environmental and social context of resource caravan passageways, environmental context is fundamental to trauma response. It is argued that resource loss and the maintaining of resource caravans are the best predictors of trauma response, both in terms of posttraumatic stress disorder and in terms of the idioms of trauma distress across cultures.

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Les innovations en matière de santé mentale mondiale se sont concentrées sur la résolution des barrières "du côté de l' offre" afin de réduire les lacunes de traitement et, ce faisant, ont redéfini les trois postulats de base des soins de santé mentale, à savoir ce que comprend une intervention en santé mentale, qui est prestataire de soins de santé mentale et ce qu'est un milieu de soins de santé mentale. Cependant, de telles innovations à elles seules ne pourront pas réduire les lacunes de traitement en raison du fossé existant entre la compréhension du trouble mental en usage chez les spécialistes en santé mentale - parfaitement illustrée dans les systèmes de diagnostic et les instruments épidémiologiques qui en découlent- et la façon dont le reste du monde conçoit la souffrance psychologique. C'est ce fossé de "crédibilité" qui nécessite d'être comblé de trois façons principales : d'abord, en distinguant entre les troubles mentaux qui pourraient bénéficier d'interventions biomédicales et les états de détresse plus bénins; en offrant des interventions pour les états de détresse par le biais principalement d'interventions psychosociales de faible intensité fournies en dehors du système de soins de santé officiel; et en basant les descriptions des catégories de diagnostics sur les formes du phénomène observées dans l'ensemble des populations, plutôt que sur celles observées en milieu spécialiste.

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The burden of mental health problems in (post)conflict low and middle income countries is substantial. Despite growing evidence for the effectiveness of selected mental health programmes in conflict affected low resource settings and growing policy support, actual uptake and implementation have been slow. A key direction for future research, and a new frontier within science and practice, is dissemination and implementation which directly addresses the transfer of evidence based, effective health care approaches from experimental settings into routine use. This paper outlines some key implementation challenges, and strategies to address these, while implementing evidence based treatments in conflict affected low and middle income countries, based on the authors' collective experiences. Dissemination and implementation evaluation and research in conflict settings is an essential new research direction. Future dissemination and implementation work in low and middle income countries should include: 1) defining concepts and developing measurement tools; 2) the measurement of dissemination and implementation outcomes for all programming; and 3) the systematic evaluation of specific implementation strategies.

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Mixed methods research, which combines elements of qualitative and quantitative research approaches, should be well suited to studying refugee mental health. However, this has not yet been adequately discussed nor demonstrated within the existing scientific literature. This paper aims to begin to fill this gap and describes how mixed methods have been used in refugee mental health research. Twenty-nine articles from the health and social sciences literature were systematically reviewed with a focus on study designs and key findings. The studies reviewed were mostly conducted in high income countries in Europe, Australia, and North America. The mixed methods studies largely involved surveys and interviews, and the designs were mostly sequential and explanatory. The key mixed methods findings were in the domains of loss of connection, loss of status, lack of adequate services and resilience. One mixed methods research example, which studied protective resources among adolescent refugees in US resettlement, is offered to illustrate some advantages of mixed methods data collection and analysis. There is, however, a need for further research on refugee mental health which takes advantage of the full spectrum of mixed methods designs to address priority needs and questions, especially involving resilience and resilience focused interventions.

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This final paper first summarises some of the major themes that previous authors have mentioned. The first theme is their endeavour to understand human beings in their ecological context. The second is that they also adhere to a (health) systems approach. The third theme refers to the proposed valuable research developments. This paper then elaborates on three ideas that deserve attention as potential ‘new frontiers’. The first is Network Mental Health, referring to the clinical staging model that may solve a range of problems: a new generation of epidemiological research that accommodates cultural expressions of distress, mitigates response bias, prevents outliers in prevalence rates, increases the cross cultural validity of psycho pathological constructs, opens venues to develop transdiagnostic treatments by non specialists, and that may help to bury the perennial universalism versus relativism debate.¹ The second idea is referred to as Community Intervention Capital. Arguing that we need interventions, beneath the primary care level within communities, as the foundations of our public mental health care system and as the crucial source of universal prevention. In low and middle income countries, this involves a wide range of community resources including: healers, teachers, community leaders, extended families and organised religion. Additionally, concerted action of all players could achieve a great deal. The third idea is called Mental Health Mathematics. Mental health professionals are ill equipped for sophisticated mathematical modelling. We need a new generation of research to study causal pathways, robustness and redundancy of interventions in order to improve equity, access to care, life course research, complex health systems and/or stigma related to mental health.

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Armed conflicts and other humanitarian crises impact mental health and psychosocial wellbeing. In contexts of overwhelming need and overstretched government health systems, nongovernmental organisations may play important roles. In this paper, we reflect on the role of Nepali nongovernmental organisations in providing mental health and psychosocial support services. In Nepal, nongovernmental organisations have provided a range of trainings, implemented interventions, organised awareness raising campaigns and conducted research on mental health and psychosocial issues in the context of political violence and natural disasters. Some have been able to capitalise on the emerging interest of humanitarian donors in mental health to strengthen the platform for sustainable mental health reforms. Nongovernmental organisations taking on such tasks have demonstrated strengths as well as presented challenges. Strengths included easy access to local communities, better understanding of local contexts, quick and flexible response mechanism and access to marginalised populations and under served areas. Challenges have included a lack of programme sustainability, weak collaboration and high staff turnover. Similarly, due to a lack of accreditation of training courses and rigorous monitoring of services, it has been difficult to independently verify the quality of services provided by nongovernmental organisations. Based on observations, the authors highlight the importance of: the integration of mental health into the broader humanitarian, health and social systems; strong partnerships with governments; strong alliances between nongovernmental organisations for more effective advocacy with policy makers; a focus on monitoring, evaluation and research; standardisation of training curriculums and clinical services; and a focus on anti-stigma interventions.

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In this paper, the authors elaborate on a model proposed in 2010 that identifies major sources of stress affecting mental health among war affected populations. That model emphasised the importance of what was termed ‘daily stressors’, as well as direct exposure to war related violence as predictors of mental health status The authors first summarise the original model and discuss the widespread response to the 2010 paper among researchers and practitioners working in conflict and post conflict settings. Then, the authors expand on the model, suggesting that, like the trauma focused model it was meant to improve upon, the proposed 2010 model still presents an overly static view of the experience of living through organised violence. A transactional version of the model is now proposed, which the authors believe more closely approximates the lived experience of war and the multiple sources of stress it entails. Implications of this transactional model, and possible directions for future research and practice, are suggested.

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Las innovaciones en la salud mental mundial se han centrando en abordar las barreras del «lado de la provisión» para reducir la brecha de tratamiento y, al hacerlo así, han redefinido tres supuestos básicos relacionados con la atención de la salud mental, es decir, qué debería incluir una intervención de atención de la salud metal, quién es un profesional sanitario y qué es un servicio de atención de salud mental. Sin embargo, este tipo de innovaciones por sí solas no van a reducir la brecha en el tratamiento en función de la brecha entre el entendimiento del trastorno mental que especialistas en salud mental utilizan, mejor ilustrada mediante los sistemas de diagnóstico y los instrumentos epidemiológicos derivados de ellos, y cómo el resto del mundo conceptualiza el sufrimiento psicológico. Esta brecha de «credibilidad» necesita ser superada de tres maneras: en primer lugar, distinguir trastornos mentales que podrían beneficiarse de intervenciones biomédicas desde estados de ansiedad más leves; ofrecer intervenciones a estados de distrés principalmente a través de intervenciones psicosociales de baja intensidad ofrecidas fuera del sistema de atención de la salud formal y basarse en las descripciones de categorías de diagnóstico en los patrones de fenómenos observados en la población general, más que aquellas observadas en entornos especializados.

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