Joint effect of maternal depression and intimate partner violence on increased risk of child death in rural Ethiopia.

OBJECTIVES: To assess independent and interaction effect of experience of intimate partner violence and depression on risk of child death. DESIGN: Community-based cohort design. SETTING: The study was conducted within the demographic surveillance site of Butajira Rural Health Program in south central Ethiopia. PARTICIPANTS: Women (n=561) who gave birth to a live child. MAIN OUTCOME MEASURES: Exposure status comprising physical, sexual and emotional violence by intimate partner was based on the WHO multi-country questionnaire on violence against women. Depression status was measured using the Composite International Diagnostic Interview. Risk of child death and its association with maternal exposure to violence and/or being depressed was analysed by incidence, rate ratios and interaction. RESULTS: The child death in the cohort was 42.1 (95% CI, 32.7 to 53.5) children per 1000 person years, and maternal depression is associated with child death. The risk of child death increases when maternal depression is combined with physical and emotional violence (RR=4.0; 95% CI, 1.6 to 10.1) and (RR=3.7; 95% CI, 1.3 to 10.4), showing a synergistic interaction. CONCLUSION: An awareness of the devastating consequences on child survival in low income setting of violence against women and depression is needed among public health workers as well as clinicians, for both community and clinical interventions.

Problem drinking among patients attending primary healthcare units in Kampala, Uganda.

OBJECTIVE: Previous studies have shown that a large a number of primary health care patients have alcohol related problems and very few are detected and treated. Few studies have been done in developing countries on this topic. This study sought to determine the prevalence and detection of alcohol related problems in a Primary Health Care setting (PHC). in Kampala Uganda. METHOD: 768 consecutive PHC patients in two PHC centers in Kampala, Uganda, were screened in a two stage procedure. After being asked if they drink alcohol they were interviewed by means of the CAGE questionnaire and a quantity/frequency questionnaire. Those who scored positive on the CAGE were further diagnosed for alcohol dependence using the DSM- IV diagnostic criteria. RESULTS: Of all patients, 17.4% scored above cut-off on the CAGE, 28.5% had a high risk drinking pattern and 9.5% had alcohol dependence. Among drinkers, drinking beyond safe limit was more common among men. Males and those aged between 35 to 44 years, were more likely to be CAGE positive and to be diagnosed with alcohol dependence. Only 27 out of 366 drinkers were asked about alcohol by the PHC professional. Males and high risk drinkers were more likely to be asked. CONCLUSION: Prevalence of alcohol problems was high and detection rate of alcohol related problems was low in this Ugandan setting. Training of PHC professionals in diagnosing and treating alcohol related problems is required.

Depression among women in rural Ethiopia as related to socioeconomic factors: a community-based study on women in reproductive age groups.

BACKGROUND: Several previous studies have reported on socioeconomic and sociodemographic factors associated with depression among women, but knowledge in this area remains scarce regarding women living in extreme poverty in developing countries. OBJECTIVE: The study was aimed at examining the 12-month prevalence of depressive episodes as related to socioeconomic and sociocultural conditions of women in the reproductive age group in rural Ethiopia. METHODS: A community-based cross-sectional study was undertaken among 3016 randomly selected women in the age group 15-49 years. Cases of depression were identified using the Amharic version of the Composite International Diagnostic Interview. A standardized World Health Organization questionnaire was used to measure the socioeconomic status of the women and their spouses. Data were analysed among all women and then separately among currently married women. RESULTS: The 12-month prevalence of depression among all women was 4.4%. After adjusting for common sociodemographic characteristics, only marital status showed a significant association with depressive episode in terms of higher odds ratios (ORs) for divorced/separated women and widowed women than for not-married women (4.05 and 4.24, respectively). Among currently married women, after adjusting for common sociodemographic characteristics, living in rural villages (OR=3.78), a frequent khat-chewing habit (OR=1.61), having a seasonal job (OR=2.94) and being relatively better off in terms of poverty (OR=0.48) were independently associated with depression. CONCLUSIONS: The prevalence of depression among women was in the lower range as compared to studies from high-income countries, but very poor economic conditions were associated with a higher prevalence of depression in this overall very poor setting. This further supports the notion that the relative level of poverty rather than the absolute level of poverty contributes to depression among women. Whether the association with khat chewing and depression is a causative effect or can be explained by self-medication remains unclear.

Pathways to suicidal behaviour among adolescent girls in Nicaragua.

Adolescent girls are the most frequent suicide attempters worldwide. However, there is little knowledge about pathways leading to suicidal behaviour among young people, in particular in low-income countries. This study explores the motives and processes related to suicidal behaviour among young girls in Nicaragua. Individual in-depth interviews were conducted with eight girls aged between 12 and 19 admitted to hospital after attempting suicide. The audio-taped interviews lasted 2-4 h and were transcribed, translated into English and coded for content. Grounded theory and content analysis were used to construct a theory of the mechanisms behind their suicidal behaviour. A tentative model exploring pathways to suicidal behaviour is described with four main categories: structuring conditions, triggering events, emotions and actions taken. The model illustrates the dialectic interplay between structure and actions taken. Actions taken were categorized as problem solving or various forms of escape where failure with either of these strategies resulted in a suicide attempt. Dysfunctional families, absent fathers and lack of integration into society were some of the structuring conditions that lead to emotional distress. Abuse, deaths in the family, break-up with boyfriends or suicide among friends acted as triggering events. A striking finding was the obvious narrative competence of the girls. Our findings indicate that suicide prevention programmes for young people must offer support from professionals, independent of their family and social networks. Institutions in the community in contact with young people with suicidal behaviour must develop communicative skills to offer a trusting environment mobilising the resources that young people have.

Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: a community-based study.

BACKGROUND: Bipolar disorders have been extensively studied in the high-income countries but community-based studies from low-income countries are very rare. The main objectives of the current study are to estimate the lifetime prevalence of bipolar I disorder in the general population of the Butajira district in Ethiopia and to characterize the onset and course of the disorder in a predominantly treatment naïve population. METHOD: Cases were identified by a door-to-door screening of the district's entire adult population aged 15 to 49 years (N=83,387), where 68,378 were successfully screened. CIDI and key informant method were used in the first stage of screening followed by confirmatory SCAN interviews. RESULTS: Three hundred fifteen cases were identified and complete information could be collected for 295 individuals. Of these, 55.3% were males, 83.1% were from a rural area, and 70.2% were illiterate. Lifetime prevalence of bipolar I disorder was estimated to be 0.6% for males and 0.3% for females. The mean age of cases was 29.5 years, with no significant sex difference. The mean age of first recognition of illness was 22.0 years; for men 22.3 years and for women 21.2 years. The mean age at onset of manic phase of the illness was found to be 22.0 years (22.5 for men and 21.4 for women). The mean age at onset of depressive phase was 23.4 years (24.1 for men and 22.5 for women). There was no significant sex difference in the age of onset of manic or depressive phases. In 22.7% of the cases bipolar I illness started with a depressive episode and in 77.3% of the cases it started with a manic episode. Two or more episodes of the illness were reported by 64.1%. Over half of the study subjects (55.9%) had never sought any help from modern healthcare sector, and only 13.2% had ever been admitted to psychiatric hospital. During the survey 7.1% of the cases were undergoing treatment. A previous suicide attempt was reported by 8.1% of the males and 5.4% of the females. CONCLUSION: The overall lifetime prevalence and age of onset are within the range of findings from other studies in Western countries. In contrast to most previous studies, prevalence of the disorder among females was half of that among males. Our finding that prevalence of this disorder among males and females appeared to be different from many other studies warrants further research.

Neurological soft signs in bipolar I disorder patients.

BACKGROUND: Neurological soft signs (NSS) have been reported to be more prevalent in patients with schizophrenia compared to other psychiatric and non-psychiatric controls. However, this issue in bipolar I disorder seems to be understudied. AIMS: The aims of the study were to examine the extent to which NSS are associated with bipolar I disorder cases compared to healthy controls, to assess the possible relationship between NSS and clinical dimensions of the disorder, and to explore the association of sociodemographic characteristics with the occurrence of NSS in cases with this disorder. METHODS: Predominantly treatment naïve cases of bipolar I disorder from rural communities were assessed for NSS using the Neurological Evaluation Scale (NES). RESULTS: This study showed that patients with bipolar I disorder performed significantly worse on two NES items from the sensory integration subscale, on one item from motor coordination and on four items from the 'others' subscale, the highest difference in performance being in items under the sequencing of complex motor acts subscale. Clinical dimensions and sociodemographic characteristics appeared to have no relationship with NES total score. CONCLUSIONS: Bipolar I disorder patients seem to have more neurological dysfunction compared to healthy controls particularly in the area of sequencing of complex motor acts. In addition, the finding suggests that NSS in bipolar I disorder are stable neurological abnormalities established at its onset or may be essential characteristic features of the disorder representing stable disease process that existed long before its onset.

Onset and clinical course of schizophrenia in Butajira-Ethiopia--a community-based study.

BACKGROUND: There are reports on favourable course and outcome of schizophrenia in lowincome countries. The aim of the present study was to examine onset and clinical course of the illness in a community-based sample in rural Ethiopia based on crosssectional information. METHOD: A two-stage survey was carried out in Butajira-Ethiopia, a predominantly rural district. Altogether 68,378 individuals aged 15-49 years were CIDI-interviewed, of whom 2,159 were identified as cases according to the CIDI interview with regard to psychotic or affective disorders. Key informants identified another group of 719 individuals as being probable cases and a total of 2,285 individuals were SCAN-interviewed. The present paper reports on cases with schizophrenia. RESULTS: There were 321 cases of schizophrenia giving an estimated lifetime prevalence of 4.7/1,000). Of the cases,83.2% (N = 267) were males. Mean age of first onset of psychotic symptoms for males was 23.8 (sd 8.6) compared to 21.0 (sd 7.8) for females (P = 0.037; 95 %CI 0.16-5.47). Over 80% had negative symptoms and over 67% reported continuous course of the illness. Less than 10% had a history of previous treatment with neuroleptic medication. About 7% were vagrants, 9 % had a history of assaultive behaviour,and 3.8% had attempted suicide. The male to female ratio was nearly 5:1. CONCLUSION: This large community-based study differs from most previous studies in terms of higher male to female ratio, earlier age of onset in females and the predominance of negative symptoms.

Schizophrenia: illness impact on family members in a traditional society--rural Ethiopia.

BACKGROUND: Studies have consistently shown that both the subjective and objective dimensions of burden among family members of schizophrenia patients and other psychiatric disorders are prevalent. However, as most of these reports were from western societies, we lack information on the subject in developing countries. METHOD: The study was conducted within the framework of the ongoing epidemiological study of course and outcome of schizophrenia and bipolar disorders in a rural population of 15-49 years of age. Three hundred and one cases of schizophrenia and their close relatives participated in the study. RESULTS: Family burden is a common problem of relatives of cases with schizophrenia. Financial difficulty is the most frequently endorsed problem among the family burden domains (74.4 %). Relatives of female cases suffered significantly higher social burden (Z = 2.103; p = 0.036). Work (Z = 2.180; p = 0.029) and financial (Z = 2.088; p = 0.037) burdens affected female relatives more often than males. Disorganised symptoms were the most important factors affecting the family members in all family burden domains. Prayer was found to be the most frequently used coping strategy in work burden (adj. OR = 1.99; 95 % CI = 1.08-3.67; p = 0.026). CONCLUSION: Negative impact of schizophrenia on family members is substantial even in traditional societies such as those in Ethiopia where family network is strong and important. The scarce existing services in the developing countries should include family interventions and support at least in the form of educating the family members about the nature of schizophrenia illness and dealing with its stigma and family burden.

Neurological soft signs (NSS) in 200 treatment-naïve cases with schizophrenia: a community-based study in a rural setting.

Several studies have reported neurological soft signs (NSS) to be common in individuals with schizophrenia. The majority of these studies are based on clinical samples exposed to neuroleptic treatment. The present study reports on 200 treatment-naïve and community-identified cases of schizophrenia and 78 healthy individuals from the same area, evaluated using the Neurological Evaluation Scale (NES). The median NES score was 5.0 for cases of schizophrenia and 1.5 for healthy subjects. The impairment rate of NSS in cases with schizophrenia was 65.0% against 50.0% in healthy subjects, and the difference was statistically significant (chi2 = 5.30; df = 1; P < 0.021). NSS abnormality is as common in treatment-naïve cases as reported in many studies in those on neuroleptic medication. There was no significant relation between the NSS impairment and duration of illness, remission status, positive symptoms, negative symptoms and disorganized symptoms.

An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia.

BACKGROUND: Detecting cases with psychiatric disorders in the general population is costly and it is not clear which is the method of choice for community surveys in low-income countries. AIM: To compare the performance of a standardized diagnostic layman interview instrument--the Composite International Diagnostic Interview (CIDI 2.1) versus the Key Informant method in identifying cases with schizophrenia and major affective disorders in a community survey. METHOD: Both screening methods were tested against an expert interview--the Schedule for Clinical Assessment in Neuropsychiatry (SCAN 2.1) in a rural district in Ethiopia with 25,632 inhabitants. RESULT: CIDI identified 524 and key informants 192 individuals as probable cases who were invited for a further SCAN interview. Seventy-two individuals were identified by both methods. Of those identified as probable cases by either method, a total of 481 volunteered the SCAN interviews. The Key Informant method alone detected more cases of schizophrenia, 59 vs. 29 for CIDI, whereas CIDI alone detected more cases of affective disorders, 45 vs. 30. Key informants performed better in detecting chronic cases. CONCLUSION: For community surveys, which aim at identifying cases with major mental disorders in low-income countries like Ethiopia, the combined use of both CIDI and the Key Informant method is recommended.

Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia.

BACKGROUND: Many studies from the Western world have reported on stigmatisation of people with mental illnesses and its negative consequences, but few studies have addressed the issue in traditional rural societies. The present study aimed to estimate the extent and socio-demographic distribution of stigma as perceived by relatives of mentally ill individuals in rural Ethiopia. METHOD: A total of 178 relatives of individuals who were diagnosed as suffering from schizophrenia or major affective disorders in a community-based survey were interviewed using the Family Interview Schedule. RESULTS: About 75% of the respondents perceived that they were stigmatised or had experienced some sort of stigma due to the presence of mental illness in the family, 42% were worried about being treated differently and 37% wanted to conceal the fact that a relative was ill. Those from the older age group (45+) and urban residents were more likely to perceive stigma as a major problem, but otherwise differences were few between socio-demographic groups. The illness was attributed to supernatural forces by 27% and praying was suggested as a preferred method to deal with the problem by 65%. CONCLUSION: Stigma was found to be a common problem, with few differences between socio-demographic groups or between types of mental disorder. Beliefs about causes differ from those held by professionals. Popular beliefs and attitudes must be taken into account when planning for intervention.

Psychological impact of the hurricane Mitch in Nicaragua in a one-year perspective.

BACKGROUND: Whereas natural disasters more commonly occur in low-income countries, almost all studies on psychological consequences have been conducted in the Western world. In countries where resources are poor it is of importance to know which groups should be targeted for early intervention after a disaster. The study aims at assessing the prevalence of post-traumatic stress disorder PTSD and of post-traumatic symptoms among people afflicted by hurricane Mitch in Nicaragua and at identifying risk factors for PTSD symptoms 6 months following a disaster. METHOD: At four primary health care centres, 496 consecutive adult patients were interviewed 6 months after hurricane Mitch regarding PTSD symptoms (Harvard Trauma Questionnaire, HTQ), disaster experiences and post-disaster help-seeking. RESULTS: All individuals resident in the area during Mitch were judged to have experienced a trauma fulfilling A criteria for PTSD. Regarding more specific traumas, 39% reported a close relative to be dead or seriously injured and 72% had their house partly or completely destroyed. Prevalence of PTSD ranged from 9.0% in the worst afflicted area to 4.5% in a less damaged area. From a dimensional perspective, PTSD symptoms according to HTQ 6 months after the disaster were significantly associated with the death of a relative (beta-coefficient 0.257, P = 0.000), a house destroyed (beta-coefficient 0.148, P = 0.001), female sex (beta-coefficient 0.139, P = 0.001), previous mental health problems (beta-coefficient 0.109, P = 0.009) and illiteracy (beta-coefficient 0.110, P = 0.009). Those with previous mental health problems (OR = 4.84; 95% CI = 3.04-7.66) were more likely than others to seek from help, any source whereas the opposite was true for illiterate people (OR = 0.38; 95% CI = 0.21-0.69). Of all respondents, 8.5% reported that they had thought of taking their lives, and illiterates (OR 2.84; 95% CI = 1.12-4.37) and those with previous mental health problems (OR 2.84; 95% CI = 1.12-4.57) were at particular risk for suicidal problems. One year after Mitch, half of those identified as PTSD cases at 6 months still fulfilled the criteria for a PTSD diagnosis. CONCLUSION: PTSD represents a serious mental health problem after a disaster. Those with illiteracy, females and those with previous mental health problems should be targets for early post-disaster intervention.

Men with schizophrenia who behave violently: the usefulness of an early- versus late-start offender typology.

Persons who develop schizophrenia are more likely than nondisordered persons to commit crimes. It is important to investigate those who offend, in order to develop treatment programs that effectively prevent recidivism, and eventually, early childhood violence prevention programs. Recent studies have shown that among offenders with major mental disorders, there are two groups: early starters, who begin their criminal careers in adolescence; and late starters, who first offend as adults. The present study examined 272 violent male offenders with schizophrenia in Sweden who underwent a pretrial psychiatric assessment between 1988 and 1995. Early- and late-start offenders were found to present differences in behavior, comorbid disorders, personality traits, and referrals for treatment in childhood, adolescence, and adulthood. Their parents also differed. The findings have implications for treatment and management of offenders with schizophrenia, for risk assessment, and for prevention.

[Psychogenic paralysis. A prospective study]. / Psykogene lammelser. Et prospektivt studium.

INTRODUCTION: Patients with motor conversion disorder are frequently seen in neurological departments. Long term prognosis is usually considered to be good, although earlier research has been somewhat unsystematic and mostly retrospective. This study follows a well investigated sample of patients for two to five years and attempts to identify predictors associated with prognosis. MATERIAL AND METHODS: Thirty patients with a recent onset of motor conversion disorder were assessed for key psychiatric and demographic variables. They were reassessed two to five years later. RESULTS: Nineteen patients had recovered completely and eight patients had improved, while only three patients were unchanged or worse. Contrary to other follow-up studies none of the patients received a rediagnosis of neurological disease. The presence of a personality disorder, concomitant somatic disease, and low DSM-IV axis V score proved to be associated with poor outcome. DISCUSSION: The results of this study stresses the need for careful and well-conducted neurological and psychiatric assessments in patients with psychogenic paralyses, bearing in mind the substantial possibility for coinciding illnesses. If this is ensured, it appears that the risk of subsequent neurological rediagnosis is negligible.

Season of birth variations in dimensions of functioning evaluated by the diagnostic interview for borderline patients.

In view of recent reports showing that cerebrospinal fluid (CSF) levels of monoamine metabolites exhibit season of birth variations, and that they are also associated with section II (impulse action patterns) of the diagnostic interview for borderline patients (DIB), we analyzed two samples of data to investigate the relationship between the season of birth and the DIB. The first sample comprised 202 patients participating in psychobiological research in Stockholm, and the second sample comprised 130 patients who had committed suicide in Västerbotten in northern Sweden. Those with intermediate score for section II (impulse action patterns) were significantly more likely to have been born during the season October to January in the pooled data, and this tendency persisted in separate analyses for the two samples and for the two diagnostic groups mood disorders and schizophrenia, respectively. Those with high score for section IV (psychosis) were significantly more likely to have been born during February to April in the pooled sample and in the nonschizophrenic group. In the group with schizophrenia, those born during February to April had significantly high scores for section III (affects). These results throw further light on the role of season of birth in suicidology and in psychiatric morbidity.

Psychopathy (PCL-R) as a predictor of violent recidivism among criminal offenders with schizophrenia.

Hare's Psychopathy Checklist--Revised (PCL-R) was used to test the hypothesis that psychopathy predicts violent recidivism in a cohort subjected to forensic psychiatric investigation and consisting of male violent offenders with schizophrenia (N = 202). Psychopathy was assessed with retrospective file-based ratings. Mean follow-up time after detainment was 51 months. Twenty-two percent of the offenders had a PCL-R score > or = 26 (cutoff), and the base rate for violent recidivism (reconvictions) during follow-up was 21%. Survival analysis revealed that psychopathy was strongly associated to violent recidivism (log-rank = 17.71, df = 1, p < 0.0001). The area under the curve (AUC) of the receiver operating characteristics (ROC) of PCL-R total score to predict violent recidivism varied between different time frames from .64 to .75. Cox regression analyses revealed that other potential risk factors could not equally well or better explain violent recidivism in the cohort than psychopathy as measured by PCL-R.

How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia.

One hundred key informants were interviewed about their awareness, attitudes and practices regarding mental illness using the Key Informant Questionnaire developed by WHO. Case vignettes of seven common neuropsychiatric disorders were presented to the key informants. Informants' awareness about these disorders and help-seeking practices for mental and physical symptoms or conditions were assessed. An additional question on the prototype symptoms of mental disorders was also posed. Among the presented seven conditions, epilepsy was perceived as the most common condition and major depression was regarded as the least common one. Schizophrenia was judged as the most severe problem, and mental retardation was considered the second most severe condition. Talkativeness, aggression and strange behaviour were the most frequently perceived prototype symptoms of mental illness. Traditional treatment methods were preferred more often for treating symptoms of mental disorders and modern medicine was preferred more often for treating physical diseases or symptoms. Findings of this study are similar to other studies conducted in socio-culturally different communities. Working in close connection with traditional healers would give the primary health care worker a better opportunity to gain acceptance from the community and modify certain harmful practices.

The prevalence and socio-demographic correlates of mental distress in Butajira, Ethiopia.

A cross-sectional survey was conducted on 10,468 rural and semi-urban adults in an Ethiopian district using the Self Reporting Questionnaire (SRQ) to detect the prevalence of mental distress and its association with socio-demographic risk factors. Fifty-eight per cent of the study population were women, 74% were Muslim, 79% were illiterate. Those experiencing 11 or more symptoms out of the 20 SRQ items were considered as having mental distress. Accordingly, the prevalence of mental distress was 17%, which is comparable with the previous hospital-based studies in Ethiopia and elsewhere. However, it was higher than the previous community-based studies in Ethiopia. Mental distress was more prevalent among women. Part of the explanation was that women in the study population were older and that they were more often widowed or divorced, which were factors associated with mental distress. Illiteracy, which was more common among women and older individuals, was also independently associated with mental distress.