Trauma related psychiatric disorders and their correlates in a clinical sample: A cross-sectional study in trauma affected patients visiting a psychiatric clinic in Nepal.

BACKGROUND: Nepal, like many other low-income countries, has a great burden of mental health issues but few resources to meet them. In addition, Nepal has endured several traumatic events in recent decades but the impact on mental health has not been studied in clinical settings. This study explores trauma-related psychiatric disorders and their correlates. METHODS: 100 patients with a history of trauma who visited the outpatient psychiatry clinic at a University hospital in Kathmandu were assessed. The Composite International Diagnostic Interview 2.1 (CIDI) was used to evaluate lifetime and current depressive disorder, generalized anxiety disorder (GAD) and lifetime post-traumatic stress disorder (PTSD). Current PTSD was evaluated using PSTD Checklist-Civilian Version (PCL-C). RESULTS: The median number of lifetime traumatic events was two. Natural disaster was the most common trauma type (84%) compared to other types of trauma. Rape was reported as the most traumatizing. Current PTSD was found in 15%, depression in 33% and GAD in 38% of the patients. The lifetime rates were PTSD 83%, depression 45% and GAD 40%. There was high comorbidity between the disorders. The 31 to 45 years age group, above high school education level and trauma types other than earthquake were independently associated with current PTSD. Marital status and upper socioeconomic status (SES) compared to upper-middle SES were independently associated with lifetime PTSD. Both lifetime and current depression rates were independently associated with the upper SES compared to upper-middle SES. Place of living, education above high school and lower-middle SES were significantly associated with lifetime and current GAD. CONCLUSION: PTSD, depression and GAD were prevalent in a trauma exposed patient population visiting a psychiatric clinic in Nepal. High rates of comorbidities and several risk factors were identified. Our findings highlight the need for addressing trauma related disorders in clinical settings in developing countries.

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.

Political violence and mental health in Nepal: prospective study.

BACKGROUND: Post-conflict mental health studies in low-income countries have lacked pre-conflict data to evaluate changes in psychiatric morbidity resulting from political violence. AIMS: This prospective study compares mental health before and after exposure to direct political violence during the People's War in Nepal. METHOD: An adult cohort completed the Beck Depression Inventory and Beck Anxiety Inventory in 2000 prior to conflict violence in their community and in 2007 after the war. RESULTS: Of the original 316 participants, 298 (94%) participated in the post-conflict assessment. Depression increased from 30.9 to 40.6%. Anxiety increased from 26.2 to 47.7%. Post-conflict post-traumatic stress disorder (PTSD) was 14.1%. Controlling for ageing, the depression increase was not significant. The anxiety increase showed a dose-response association with conflict exposure when controlling for ageing and daily stressors. No demographic group displayed unique vulnerability or resilience to the effects of conflict exposure. CONCLUSIONS: Conflict exposure should be considered in the context of other types of psychiatric risk factors. Conflict exposure predicted increases in anxiety whereas socioeconomic factors and non-conflict stressful life events were the major predictors of depression. Research and interventions in post-conflict settings therefore should consider differential trajectories for depression v. anxiety and the importance of addressing chronic social problems ranging from poverty to gender and ethnic/caste discrimination.

Political violence and mental health: a multi-disciplinary review of the literature on Nepal.

Implementation of current international consensus guidelines regarding mental health and psychosocial support in emergencies requires the consideration of findings from both the medical and social sciences. This paper presents a multi-disciplinary review of reported findings regarding the relations between political violence, mental health and psychosocial wellbeing in Nepal. A systematic search of six databases resulted in the identification of 572 studies, of which 44 were included in the review. These studies investigated the influence of political violence on contextual variables that shape mental health and psychosocial wellbeing, and examined psychological distress and mental disorders in the context of political violence. The majority of studies addressed the mental health of Bhutanese refugees in Nepal and the impact of the Maoist People's War. Based upon these results from Nepal, we discuss a number of issues of concern to international researchers and practitioners and present policy and research recommendations. Specifically, we consider (a) the need for longitudinal multi-disciplinary research into protective and risk factors, including agency, of psychological distress and mental disorders in situations of political violence, (b) the continuing controversy regarding the PTSD construct, and (c) the lack of robust findings regarding the effectiveness of mental health and psychosocial support.

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.

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.

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.