Conflict and mental health: a cross-sectional epidemiological study in Nepal.

PURPOSE: The aim of this epidemiological study was to identify prevalence rates of mental health problems, factors associated with poor mental health and protective and risk factors in a post-conflict situation in Nepal. METHODS: This cross-sectional study was conducted among 720 adults in 2008. A three-stage sampling procedure was used following a proportionate stratified random sampling strategy. The outcome measures used in the study were locally validated with Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Post-Traumatic Stress Disorder (PTSD)-Civilian Version (PCL-C) and locally constructed function impairment scale, resources and coping. RESULTS: Of the sample, 27.5% met threshold for depression, 22.9% for anxiety, and 9.6% for PTSD. Prevalence rates were higher among women (depression, OR 2.14 [1.52-3.47]; anxiety, OR 2.30 [1.45-3.17] and PTSD, OR 3.32 [1.87-5.89]) and older age categories (depression, OR 1.02 [1.01-1.04]; anxiety, OR 1.04 [1.03-1.05] and PTSD, OR 1.02 [1.0-1.03]). Respondents who perceived more negative impact of the conflict (e.g., hampered the business/industry; hindered in getting medical treatment, etc.) in their communities were more at risk for depression (OR 1.1 [1.06-1.14]), anxiety (OR 1.05 [1.01-1.09]) and PTSD (OR 1.09 [1.04-1.14]). Other risk factors identified in the study were ethnicity, district of residence and poverty (lack of clothing, medicine and information via radio at home). CONCLUSION: Overall, the prevalence rates of depression and anxiety in the sample are comparable to, or lower than, other studies conducted with populations affected by conflict and with refugees. However, the findings underscore the need to address the current lack of mental health care resources in post-conflict rural Nepal, especially for marginalized populations.

Brief multi-disciplinary treatment for torture survivors in Nepal: a naturalistic comparative study.

BACKGROUND: Little is known about the effectiveness of treatment for torture survivors in low-income settings. Multi-disciplinary treatment is an often used approach for this target group. AIMS: This study was aimed at examining the effectiveness of brief multi-disciplinary treatment for torture survivors in Nepal. METHODS: A naturalistic comparative design with help-seeking torture survivors and internally displaced persons assigned to a treatment and a comparison group respectively ( n = 192; treatment group n = 111, comparison group n = 81), with baseline measurements on psychiatric symptomatology, disability, and functioning and a five-month follow-up (n = 107; treatment group n = 62; comparison group n = 45), was employed. Intervention consisted of brief psychosocial services, minimal medical services and/or legal assistance. RESULTS: Study groups were generally comparable and non-completers did not significantly differ from completers. The treatment group improved more than the comparison group on somatic symptoms, subjective well-being, disability and functioning, with mostly moderate effect sizes. CONCLUSION: Treatment was moderately effective, with regards to reducing the nonspecific mental health consequences of torture, but disability scores remained high. For clients presenting with more severe mental health problems, other treatments that are realistic in the resource-poor Nepali context need to be sought.

Cultural challenges to psychosocial counselling in Nepal.

This article describes the way in which the practice of psychosocial counselling was adapted culturally to the context of Nepal within the Centre for Victims of Torture, Nepal (CVICT). After a brief description of the Nepali setting and CVICT's counselling and training approach and the relationship of its psychosocial counselling intervention with existing methods of dealing with psychosocial problems, the cultural challenges of implementing psychosocial counselling and our response to them are sketched along with concepts deemed important in psychosocial counselling. A discussion follows in which the authors' stance on the export of psychosocial counselling to non-western cultures is outlined.

Psychiatric disability among tortured Bhutanese refugees in Nepal.

OBJECTIVE: Most refugees live in low-income countries. There is a lack of data on psychiatric disability among such refugees. The authors compared psychiatric disability in tortured and nontortured Bhutanese refugees living in Nepal and examined factors associated with psychiatric disability among the tortured refugees. METHOD: A cross-sectional survey was conducted among 418 tortured and 392 nontortured Bhutanese refugees, matched for age and gender. The Composite International Diagnostic Interview, version 2.1, and the World Health Organization Short Disability Assessment Schedule were used to measure ICD-10 psychiatric disorders and disability, respectively. RESULTS: Approximately one in five tortured and nontortured Bhutanese refugees were found to be disabled. Posttraumatic stress disorder, specific phobia, and present physical disease were identified as factors associated with disability among the tortured refugees. On the other hand, present physical disease, greater age, and generalized anxiety disorder were associated with disability among the nontortured group. CONCLUSIONS: These findings show that the tortured and nontortured refugees were equally likely to be disabled. Different sets of predictors were identified among tortured and nontortured refugees, indicating the need for comprehensive psychiatric assessment of both tortured and nontortured refugees in clinical practice.

Disability associated with psychiatric symptoms among torture survivors in rural Nepal.

Our objective was to explore the relationships between psychiatric symptom categories (posttraumatic stress disorder (PTSD), anxiety, and depression) and disability among torture survivors. We conducted a cross-sectional study of help-seeking torture survivors in highly affected conflict areas in rural mid-Western Nepal, using rating scales to assess symptomatology and disability. Validated screening instruments for the Nepali setting revealed that a high amount of psychopathology was present. Exploration of the relationships between psychiatric symptomatology and disability showed a central role for PTSD and anxiety complaints, but not for depressive complaints. A recursive model in which PTSD has (a) a direct relationship with disability and (b) an indirect relationship with disability mediated by anxiety and depression best fits the data. Findings are consistent with research on tortured refugees, suggesting the importance of a PTSD-anxiety mechanism. Implications for refugees in Western settings are discussed. Complexity of the mental status of torture survivors indicates multidisciplinary treatment.

The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: examination of comorbidity with anxiety and depression.

Previous research has indicated a relationship between posttraumatic stress disorder (PTSD) and somatic complaints. We examined whether this relationship is a result of shared comorbidity with anxiety and depression. Local doctors interviewed a random, community sample of 526 tortured and 526 nontortured Bhutanese refugees living in U.N. refugee camps in Nepal. The interview covered demographics, torture, somatic complaints, and PTSD, depression, and anxiety measures. Number of PTSD symptoms, independent of depression and anxiety, predicted both number of reported somatic complaints and number of organ systems involving such complaints. Physicians need to screen for PTSD when survivors of extreme stressors present nonspecific somatic complaints.

Mental illness among Bhutanese shamans in Nepal.

Despite efforts to promote traditional medicine, allopathic practitioners often look with distrust at traditional practices. Shamans in particular are often regarded with ambivalence and have been considered mentally ill people. We tested the hypothesis that shamanism is an expression of psychopathology. In the Bhutanese refugee community in Nepal, a community with a high number of shamans, we surveyed a representative community sample of 810 adults and assessed ICD-10 mental disorders through structured diagnostic interviews. Approximately 7% of male refugees and 0.5% of female refugees reported being shamans. After controlling for demographic differences, the shamans did not differ from the comparison group in terms of 12-month and lifetime ICD-10 severe depressive episode, specific phobia, persistent somatoform pain, posttraumatic stress, generalized anxiety, or dissociative disorders. This first-ever, community-based, psychiatric epidemiological survey among shamans indicated no evidence that shamanism is an expression of psychopathology. The study's finding may assist in rectifying shamans' reputation, which has been tainted by past speculation of psychopathology.