Internet-delivered therapy for alcohol misuse: engagement, satisfaction, and outcomes when patients select their preference for therapist- or self-guided treatment.

BACKGROUND: Alcohol misuse is common and causes substantial harm. Internet-delivered cognitive behaviour therapy (ICBT) is effective in reducing alcohol misuse; however, the literature investigating how treatment outcomes are impacted by patients' preferences for therapist- versus self-guided ICBT for alcohol misuse is sparse. METHODS: In this preference trial, 74 eligible patients (who reported ≥ 14 drinks in the previous week and obtained scores suggesting hazardous or harmful drinking) chose between enrolling in either therapist- or self-guided ICBT for alcohol misuse. We investigated whether those who chose therapist- versus self-guided ICBT differed in their (a) drinking outcomes-as measured by Timeline Follow-Back (TLFB) and heavy drinking days (HDD) at post-treatment and 3-month follow-up-and (b) post-treatment ICBT engagement and satisfaction. RESULTS: The majority (81.1%) of eligible patients chose therapist-guided ICBT. These patients reported higher psychotropic medication use, drinking difficulties, and anxiety symptoms. For both the therapist- and self-guided patients, a modified intention-to-treat analysis revealed large within-group treatment effects for TLFB (ß = - 2.64, SE 0.66; p < 0.001) and HDD (ß = - 0.34, SE 0.07; p < 0.001), with large pre-to-post-treatment Cohen's effect sizes of d = 0.97 (95% CI [0.49, 1.45]) for TLFB and d = 1.19 (95% CI [0.69, 1.68]) for HDD. The interaction comparing the effects of therapist- to self-guided ICBT over time was not significant for TLFB (p = 0.34) or HDD (p = 0.06). With treatment, for both therapist- and self-guided patients, there was a significant improvement in drinking difficulties, cravings, and confidence with controlling cravings, as well as in anxiety, depression, and functional impairment. Further, the majority (75.7%) of patients completed five or more lessons, as well as reported overall satisfaction with the treatment (88.9%) and increased confidence in managing their symptoms (86.7%); these outcomes also did not differ between therapist- and self-guided patients. CONCLUSIONS: The current study shows that ICBT for alcohol misuse is associated with reduced drinking and comorbid mental health difficulties over time, irrespective of whether patients chose to complete the course on their own or with therapist guidance. TRIAL REGISTRATION NUMBER: NCT04611854 ( https://clinicaltrials.gov/ct2/show/NCT04611854 ).

Satisfaction, engagement, and outcomes in internet-delivered cognitive behaviour therapy adapted for people of diverse ethnocultural groups: an observational trial with benchmarking.

Introduction: Depression and anxiety are the most common mental health disorders worldwide. Internet-Delivered Cognitive Behaviour Therapy (ICBT) can reduce barriers to care to broad cross sections of the population. However, People of Diverse Ethnocultural Backgrounds (PDEGs) other than White/Caucasian underutilize mental health services and are under represented in clinical trials of psychological interventions. Methods: To address this research gap we adapted an evidence-based ICBT program for PDEGs. The current pilot study explores the engagement, satisfaction, and effectiveness in the adapted ICBT program by PDEGs (N=41) when benchmarked against a sample of PDEGs (N=134) who previously completed a non-adapted version of the ICBT program. Results: An intent-to-treat analyses showed that the adapted ICBT program is effective in reducing anxiety and depression symptoms among PDEGs. Large within-group pre-to post-treatment Cohen's effect sizes of d = 1.23, 95% CI [0.68, 1.77] and d = 1.24, 95% CI [0.69, 1.79] were found for depression and anxiety, respectively. Further, 81.8% of the PDEGs who received the adapted ICBT reported overall satisfaction, 90.9% reported increased confidence in managing symptoms, and 70.7% completed majority of the psychoeducational lessons in the ICBT program. Conclusion: No statistically significant differences in the clinical outcomes, engagement, and satisfaction were found between the pilot study and benchmark sample. Future directions for ICBT research with PDEGs are described. Clinical trial registration: https://beta.clinicaltrials.gov/study/NCT05523492, identifier NCT05523492.

Patient-Oriented Research to Improve Internet-Delivered Cognitive Behavioural Therapy for People of Diverse Ethnocultural Groups in Routine Practice.

There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community representatives, ICBT clinicians, managers, and researchers was formed. The working group examined archival feedback on ICBT from past patients who self-identified as being from diverse ethnocultural backgrounds (N = 278) and the results of interviews with current patients (N = 16), community representatives (N = 6), and clinicians (N = 3). The archival data and interviews revealed the majority of the patients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT adaptation focused on adding content related to cultural influences on mental health, addressing stigma, diversifying case stories, examples, and imagery, adding audiovisual introductions, and replacing English idioms with more descriptive language. Moreover, further training was offered to clinicians, and efforts were made to improve community outreach. This study demonstrates a process for using patient-oriented research to improve ICBT within routine care serving patients of diverse backgrounds.

The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study.

BACKGROUND: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. OBJECTIVE: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. METHODS: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients' use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients' alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. RESULTS: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients' drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. CONCLUSIONS: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.

Engagement with homework in an Internet-delivered therapy predicts reduced anxiety and depression symptoms: A latent growth curve analysis.

OBJECTIVE: Assigning homework to patients to facilitate skill development is an essential part of internet-delivered cognitive behavior therapy (ICBT). This study examined if patients' self-ratings of homework engagement, including conceptual (e.g., understandability, difficulty, perceived usefulness) and practical (e.g., effort put into reviewing the lessons, practicing skills, continuity in use of the learned skills) engagement predicts ICBT outcomes for anxiety and depression using a subsample of data from a previously published randomized controlled trial. METHOD: Three hundred and one adult patients (74.56% female; 91.29% Caucasians; Mage = 36.33) randomly assigned to complete Homework Reflection Questionnaires (HWRQ) were included in this study. Patients completed the Patient Health Questionnaire (PHQ-9) and generalized anxiety disorder (GAD-7) at pretreatment, midtreatment (4 weeks), posttreatment (8 weeks), and at follow-up (12 weeks). HWRQ related to each of five lessons were completed at the beginning of the subsequent lessons or at posttreatment (e.g., Lesson 1 HWRQ completed at start of Lesson 2). Latent growth curve modeling was used to test the effect of engagement with homework activities in reduction of anxiety and depression symptoms over time. RESULTS: Patient-rated homework engagement significantly predicted rate of change in depression and anxiety symptom severity but was not significantly associated with initial levels of either outcome. Patients who reported higher engagement with assigned homework activities achieved more symptom reduction over treatment and follow-up at 12 weeks. CONCLUSION: The findings provide evidence of the importance of patients' self-rated engagement with homework in ICBT as well psychometric evidence supporting use of homework ratings to assess engagement. Further studies are needed to replicate the association between homework engagement and reduction in anxiety and depression symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Narratives of the worst experiences associated with peritraumatic distress during the COVID-19 pandemic: a mixed method study in the USA and Italy.

Background: Although symptoms of posttraumatic stress disorder (PTSD) have been associated with the COVID-19 pandemic experiences, no study has explored yet the association of specific COVID-19 narratives with peritraumatic distress, the precursor of PTSD. Objective: To explore the worst experiences associated with peritraumatic distress during the first wave of the COVID-19 pandemic. Method: Adult residents (N = 1098), from the US (n = 741) and Italy (n = 357), completed an online survey including socio-demographic data, COVID-19-related experiences, the Peritraumatic Distress Inventory and an open question on their worst experiences during the first period of the COVID-19 pandemic (April-May 2020). A thematic content analysis (TCA) was conducted on the answers to the open question and a classification and regression tree (CART) analysis was used to identify the themes that best predicted the clinical levels of peritraumatic distress. Results: The main TCA themes related to participants' worst COVID-19 experiences were anxiety, threat, loss, anger, stress and constriction. Threat was the most prevalent theme and correlated with experiences such as being quarantined, being infected and a loved one receiving the diagnosis. US participants' descriptions of their worst experiences related more to life-threat and loss, while Italians reported more threat to the world, stress, social isolation, and feeling trapped. In the CART analysis, the main predictor (79.9%) was perceiving negative effects from the COVID-19 crisis. Among them, a COVID-related threat to self-experience was the most robust predictor. In its absence, being deprived of resources or experiencing high levels of anxiety were other robust predictors. Conclusions: The study provided evidence of the utility of a mixed-method approach in conceptualizing experiences associated with the COVID-19 pandemic and the risk of traumatic symptoms. Its findings may inform healthcare interventions and policies for tackling the new challenges posed by the COVID-19 pandemic. HIGHLIGHTS Clinically significant levels of peritraumatic distress symptoms were prevalent during the COVID-19 pandemic.Clinically significant levels of peritraumatic distress during the COVID-19 pandemic were related to experiences of life-threat, resource deprivation, and anxiety, cross-cutting the themes articulated by the thematic content analysis of anxiety, threat, loss, anger, stress and constriction.The US and Italian participants' descriptions of their worst experiences differed in subtle but important ways, with Americans reporting more life-threat and losses compared to Italians reporting more threat to the world, stress, social isolation, and feelings of being trapped.

Antecedentes: Aunque los síntomas del trastorno de estrés postraumático (TEPT) se han asociado con las experiencias de la pandemia de COVID-19, ningún estudio ha explorado aún la asociación de las narrativas específicas de COVID-19 con el distres peritraumático, el precursor del TEPT.Objetivo: Explorar las peores experiencias asociadas al distres peritraumático durante la primera ola de la pandemia COVID-19.Método: Adultos residentes (N = 1098), de los EE.UU. (n = 741) e Italia (n = 357), completaron una encuesta en línea que incluía datos sociodemográficos, experiencias relacionadas con la COVID-19, el Inventario de Distrés Peritraumático y una pregunta abierta sobre sus peores experiencias durante el primer período de la pandemia de la COVID-19 (abril-mayo de 2020). Se realizó un análisis de contenido temático (TCA, en sus siglas en inglés) sobre las respuestas a la pregunta abierta y se utilizó un análisis de árbol de clasificación y regresión (CART, en sus siglas en inglés) para identificar los temas que mejor predecían los niveles clínicos de distres peritraumático.Resultados: Los principales temas del TCA relacionados con las peores experiencias de COVID-19 de los participantes fueron la ansiedad, la amenaza, la pérdida, la ira, el estrés y la constricción. La amenaza fue el tema más prevalente y se correlacionó con experiencias como estar en cuarentena, estar infectado y que un ser querido recibiera el diagnóstico. Las descripciones de los participantes estadounidenses de sus peores experiencias estaban más relacionadas con la amenaza a la vida y la pérdida, mientras que los italianos informaron más de la amenaza al mundo, el estrés, el aislamiento social y la sensación de estar atrapados. En el análisis CART, el principal predictor (79,9%) fue la percepción de efectos negativos de la crisis COVID-19. Entre ellos, la experiencia de amenaza a sí mismo relacionada con la COVID fue el predictor más sólido. En su ausencia, estar privado de recursos o experimentar altos niveles de ansiedad fueron otros predictores sólidos.Conclusiones: El estudio aportó pruebas de la utilidad de un abordaje de métodos mixtos para conceptualizar las experiencias asociadas a la pandemia de COVID-19 y el riesgo de síntomas traumáticos. Sus hallazgos pueden servir de base a las intervenciones y políticas sanitarias para afrontar los nuevos retos que plantea la pandemia de COVID-19.

Media Use During the COVID-19 Pandemic: Cross-sectional Study.

BACKGROUND: Throughout the pandemic, the general population was encouraged to use media to be kept informed about sanitary measures while staying connected with others to obtain social support. However, due to mixed findings in the literature, it is not clear whether media use in such a context would be pathogenic or salutogenic. OBJECTIVE: Therefore, the associations between COVID-19-related stressors and frequency of media use for information-seeking on trauma- and stressor-related (TSR) symptoms were examined while also investigating how social media use for support-seeking and peritraumatic distress interact with those variables. METHODS: A path model was tested in a sample of 5913 adults who completed an online survey. RESULTS: The number of COVID-19-related stressors (ß=.25; P<.001) and extent of information-seeking through media (ß=.24; P=.006) were significantly associated with the severity of TSR symptoms in bivariate comparisons. Associations between levels of peritraumatic distress and both COVID-19-related stressors and information-seeking through media, and social media use for support- and information-seeking through media were found (ßCOVID-19 stressors: Peritraumatic Distress Inventory=.49, P<.001; ßseeking information: Peritraumatic Distress Inventory=.70, P<.001; ßseeking information-seeking support=.04, P<.001). CONCLUSIONS: Results suggest that exposure to COVID-19-related stressors and seeking COVID-19-related information through the media are associated with higher levels of peritraumatic distress that, in turn, lead to higher levels of TSR symptoms. Although exposure to the stress of the COVID-19 pandemic may be unavoidable, the frequency of COVID-19-related information consumption through various media should be approached with caution.

PTSD is not the emblematic disorder of the COVID-19 pandemic; adjustment disorder is.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental disorder of the COVID-19 pandemic, assuming that PTSD's life-threat criterion was met de facto. More plausible outcomes like adjustment disorder (AD) have been overlooked. METHODS: An online cross-sectional survey was launched in the initial stage of the pandemic using a convenience sample of 5 913 adults to compare the prevalence of COVID-related probable PTSD versus probable AD. The abridged Impact of Event Scale - Revised (IES-6) assessed the severity of trauma- and stressor-related symptoms over the previous week. Demographic and pandemic-related data (e.g., receiving a formal diagnosis of COVID-19, job loss, loss of loved one, confinement, material hardship) were collected. A Classification and Regression Tree analysis was conducted to uncover the pandemic experiences leading to clinical 'caseness'. Caseness was defined by a score > 9 on the IES-6 symptom measure and further characterized as PTSD or AD depending on whether the Peritraumatic Distress Inventory's life-threat item was endorsed or not. RESULTS: The participants were predominantly Caucasian (72.8%), women (79.2%), with a university degree (85%), and a mean age of 42.22 (SD = 15.24) years; 3 647 participants (61.7%; 95%CI [60.4, 63.0]) met the threshold for caseness. However, when perceived life-threat was accounted for, only 6.7% (95%CI [6.1, 7.4]) were classified as PTSD cases, and 55% (95%CI [53.7, 56.2]) as AD cases. Among the AD cases, three distinct profiles emerged marked by the following: (i) a worst personal pandemic experience eliciting intense fear, helplessness or horror (in the absence, however, of any life-threat), (ii) a pandemic experience eliciting sadness/grief, and (iii) worrying intensely about the safety of significant others. CONCLUSIONS: Studies considering the life-threat criterion as met de facto during the pandemic are confusing PTSD for AD on most counts. This misconception is obscuring the various AD-related idioms of distress that have emerged during the pandemic and the actual treatment needs.

Tackling the global problem of traumatic stress in low-income countries: a pilot clinical trial comparing reconsolidation therapy to paroxetine in Nepal.

BACKGROUND: Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country. METHODS: Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks. RESULTS: An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (ß1 = - 4.83, 95% CI = [- 5.66, - 4.01], p < .001), whereby both groups improved, with Cohen's effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of 2.82 (95% CI = [1.98, 3.66]) for RT after 7 weeks, suggesting treatment effectiveness for both groups in a real-world setting. Three and six-month follow-up yielded further significant improvement in both groups, which did not differ from each other. CONCLUSION: RT also displayed promising efficiency, considering that it had been discontinued weeks earlier while the paroxetine treatment was continued, as recommended. RT could be taught in low-income countries as part of the local therapeutic resources to treat the core symptoms of PTSD, provided that such results are replicated on a broader scale. TRIAL REGISTRATION: ISRCTN34308454 (11/10/2017).

Characteristics of Adolescents Affected by Mass Psychogenic Illness Outbreaks in Schools in Nepal: A Case-Control Study.

This paper presents the first systematic case-control study of correlates of mass psychogenic illness (MPI) in an adolescent school population. MPI is generally construed as a dissociative phenomenon spread by social contagion to individuals who are prone to dissociation. We sought to test if the correlates of dissociative experiences most commonly proposed in the literature could predict caseness among students affected by episodes of mass psychogenic illness occurring in schools in Nepal. We assessed 194 cases and 190 controls (N = 384) of ages 11-18 years from 12 public schools. Cases and controls were comparable on all demographic variables, except for family configuration, with nuclear families more common among those affected. In bivariate comparisons, caseness was associated with childhood physical neglect and abuse, as well as living in nuclear families, peritraumatic dissociation, dissociative tendencies, and depressive and post-traumatic stress symptoms. Hypnotizability emerged as the strongest correlate of psychogenic illness among the cognitive and personality trait variables. However, in multivariable logistic regression, the correlates of dissociation did not predict caseness, suggesting that they do not adequately account for the phenomenon of mass psychogenic illness. An ad-hoc Classification and Regression Trees analysis showed that if an adolescent was highly hypnotizable and reported high rates of peritraumatic dissociative experiences, then there was a 73% probability of being a case in a mass psychogenic illness episode. Future studies involving other psychological, social and cultural factors, as well as school- and family-related factors are needed to understand the correlates of mass psychogenic illness and guide prevention and intervention.

Predictors of Dissociative Experiences Among Adolescents in Nepal: A Path Analysis.

In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.

The Long-Term Mental Health Consequences of Torture, Loss, and Insecurity: A Qualitative Study Among Survivors of Armed Conflict in the Dang District of Nepal.

Background and Objectives: Nepal has witnessed several periods of organized violence since its beginnings as a sovereign nation. Most recently, during the decade-long Maoist Conflict (1996-2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. Moreover, there is widespread gender-, ethnic- and caste-based discrimination, and grossly unequal distribution of wealth in the country. While the immediate mental health effects of the conflict are well studied, less is known about the long-term effects of the conflict. This article sets out to explain how Nepalese survivors of violence perceive their wellbeing and mental health, search for help and construct their health care pathways and therapeutic itineraries. The aim is to provide a better understanding of local explanatory models and healthcare behaviors. Methods: Semi-structured interviews were carried out with 25 people (14 men, 11 women) aged 30 to 65 in Dang district in 2013. To elicit illness narratives, a translated and culturally adapted version of the McGill Illness Narrative Interview (MINI) was used. Additionally, participants were interviewed about their war experiences and present-day economic and social situations. The transcripts were coded using deductive and inductive approaches and analyzed through thematic analysis. Results: The study provides insight into temporal narratives of illness experience and explanatory modules. Symptoms were found to be widespread and varied, and were not solely attributed to violent experiences and memories, but also to everyday stressors related to survivors' economic, social, and familial situations. In terms of help- and health-seeking behavior it was found that participants resorted to various coping strategies such as social activities, avoidance, withdrawal, and substance use. Many participants had received biomedical treatment for their psychosocial problems from doctors and specialists working in public and private sector clinics and hospitals as well as different forms of traditional healing. Conclusions: These results shed light on the long-term impact of the Nepalese conflict on survivors of extreme violence, highlighting local explanatory models and help- and health-seeking behaviors. These findings inspire recommendations for the development of context specific and holistic psychosocial interventions focusing on well-being, social determinants of health, and human rights.

"In our community, a friend is a psychologist": An ethnographic study of informal care in two Bhutanese refugee communities.

The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews ( n = 40, camp community; n = 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the "heart-mind" and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts.

A village possessed by "witches": a mixed-methods case-control study of possession and common mental disorders in rural Nepal.

In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. To identify the cultural contexts and psychosocial correlates of spirit possession, we conducted a mixed-method study in a village in central Nepal experiencing a cluster of spirit possession events. The study was carried out in three stages: (1) a pilot study consisting of informal interviews with possessed individuals, observations of the possession spells, and video recording of possession events; (2) a case-control study comparing the prevalence of symptoms of common mental disorders in women who had and had not experienced possession; and (3) a follow-up study with focus group discussions and in-depth interviews with possessed and non-possessed men and women, and key informants. Quantitative results indicated that possessed women reported higher rates of traumatic events and higher levels of symptoms of mental disorder compared to non-possessed women (Anxiety 68 vs. 18 %, Depression 41 vs. 19 %, and PTSD 27 vs. 0 %). However, qualitative interviews with possessed individuals, family members, and traditional healers indicated that they did not associate possession states with mental illness. Spirit possession was viewed as an affliction that provided a unique mode of communication between humans and spirits. As such, it functioned as an idiom of distress that allowed individuals to express suffering related to mental illness, socio-political violence, traumatic events, and the oppression of women. The study results clearly indicate that spirit possession is a multi-dimensional phenomenon that cannot be mapped onto any single psychiatric or psychological diagnostic category or construct. Clinical and public health efforts to address spirit possession must take the socio-cultural context and systemic dynamics into account to avoid creating iatrogenic illness, undermining coping strategies, and exacerbating underlying social problems.

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.