Prevalence and associated factors of depression in Sri Lanka: a systematic review and meta-analysis.

PURPOSE: Epidemiological data on depression are required to inform policies and service planning in mental health in Sri Lanka. This review aimed to synthesise data from existing studies to calculate the pooled prevalence of depression in Sri Lanka, assess its variability across subgroups, and identify associated factors within each subgroup. METHODS: PubMed, Embase, PsycINFO, Science Direct, Google Scholar and local journals were searched to identify peer-reviewed studies reporting the prevalence of depression among non-clinical adult, young, older, and maternal populations in Sri Lanka. A meta-analysis was performed using a random-effects model to calculate pooled prevalence estimates. Subgroup, sensitivity and moderator analyses were performed. A qualitative synthesis of factors associated with depression was conducted. RESULTS: A total of 33 studies representing a total of 52,778 participants were included. Overall, the pooled prevalence of depression was 19.4% [14.44-25.54%]. Among subpopulations, the highest prevalence was reported among young persons (39%); the rates in adults, older persons and maternal populations were 8.7%, 18.4% and 16.9%, respectively. Prevalence estimates were higher when based on screening instruments (21.2%) compared to diagnostic interviews (4.3%). A high degree of heterogeneity (I2 = 99.2) was observed. A qualitative synthesis of factors associated with depression, including individual attributes and behaviours, socio-economic circumstances and broader environmental factors, is reported for each age group. CONCLUSION: Approximately one-fifth of the population was detected to have depression. Notable variations in prevalence were observed across age groups. The heterogeneity of studies limits the inferences drawn from this review.

Improving psychological well-being among healthcare workers during the COVID-19 pandemic with an online mindfulness intervention: A randomised waitlist-controlled trial.

The high prevalence of psychological problems observed among healthcare workers (HCWs) during the COVID-19 pandemic called for interventions to safeguard their mental health. We assessed the effectiveness of a 6-week online mindfulness-based intervention in improving well-being and reducing stress among HCWs in Sri Lanka. Eighty HCWs were recruited and randomised into two groups: waitlist-control (WLC) and intervention groups. In the intervention, 1-hour online sessions were conducted at weekly intervals and participants were encouraged to do daily home practice. Stress and well-being were measured pre- and post-intervention using the Perceived Stress Scale and WHO-5 Well-being Index, respectively. One-way analysis of covariance was used to evaluate the effectiveness, in both intention-to-treat (ITT) and complete-case (CC) analyses. A significantly greater improvement in well-being occurred in the intervention arm compared to WLC on both ITT (p = .002) and CC analyses (p < .001), with medium-to-large effect sizes (partial η2 = .117-.278). However, the reduction in stress following the intervention was not significant compared to the WLC group on both ITT (p = .636) and CC analyses (p = .262). In the intervention arm, the median number of sessions attended by participants was 3. Low adherence to the intervention may have contributed to the apparent non-significant effect on stress.

Perceived Impact of the COVID-19 Pandemic on Psychiatric Training Among Final-Year Medical Undergraduates in Sri Lanka: an Online Survey of Students from Eight Universities.

OBJECTIVE: This study aimed to assess the perceived impact of the COVID-19 pandemic on undergraduate psychiatry training in Sri Lanka and to explore several potentially associated factors. METHODS: An online survey was distributed among students from eight medical schools who recently faced their final exam. Their perceptions on the impact of the pandemic on the psychiatry training and exam performance were rated on a 10-point scale. Resilience was assessed using a two-item scale. RESULTS: A total of 644 students responded (69.5% female, mean age=27.5 years). Among them, 164 (25.5%) reported being quarantined; 25 (4%) reported becoming infected with COVID-19; and 170 (28.6%) reported ward closure for over a week during the clerkship. Greater impact was reported for patient availability (mean=7.08), mental status assessments (mean=6.3), developing rapport (mean=6.2), and diagnostic skills (mean=5.9), whereas the impact on peer-learning (mean=5.5) and self-study (mean=3.6) was relatively lower. Impact on clinical components of the final exam (mean=6) was rated higher than on theory components (mean=4.5). The majority (70.3%) reported that COVID-19-related stress affected their exam preparations. Higher resilience predicted lower perceived impact on all aspects of training/exam performance. Female gender and ward closure predicted greater impact on diagnostic skills, overall training, and clinical exam performance, whereas being quarantined predicted greater impact on peer-learning and self-study. CONCLUSION: The pandemic has significantly affected the undergraduate psychiatry training in Sri Lanka, particularly its clinical components. Increasing clinical exposure to patients, managing students' stress, and building their resilience should be key concerns for medical educators during the pandemic.

Revisiting the ATP 30: the Factor Structure of a Scale Measuring Medical Students' Attitudes Towards Psychiatry.

OBJECTIVE: Among the scales developed for assessing medical students' attitudes regarding psychiatry, "attitude towards psychiatry-30" (ATP-30) is probably the most widely used. Although this scale was originally deemed to form a unitary dimension without any meaningful subscales, the authors sought to re-examine its factor structure and the viability of subscales. METHOD: Secondary data from a survey of 743 final-year medical students from nine medical schools in Sri Lanka were analyzed using exploratory factor analysis (EFA) with promax rotation and confirmatory factor analysis (CFA), to assess the underlying factor structure of ATP-30. Parallel analysis was used in determining the number of factors to retain. Items conceptually external to the emerging factors were discarded. RESULTS: Three models based on literature (one-, five-, and eight-factor) were disproved by CFA. A six-factor solution encompassing 18 items was supported by EFA and CFA and was gender-invariant. These factors were, namely, the image of psychiatrists, psychiatric patients and mental illness, the efficacy of treatment, psychiatric teaching, career choice, and psychiatry as an evidence-based discipline. While "the image of psychiatrists" formed the most consistent subscale (ω = 0.71), the internal consistencies of the other subscales were modest (ω = 0.55-0.67). The overall 18-item scale showed good internal consistency (ω = 0.78). CONCLUSION: The findings provide evidence of a multi-dimensional structure in medical students' attitudes towards psychiatry, endorsing six meaningful subscales of the ATP-30. Future researchers and educators can utilize these subscales in identifying specific areas where students' attitudes are more stigmatized, to be intervened during undergraduate training.

Impact of COVID-19 on the mental health of frontline and non-frontline healthcare workers in Sri Lanka.

INTRODUCTION: Healthcare workers (HCWs) are at risk of mental health problems during a pandemic. Being stationed at the frontline or not may have implications on their mental health. OBJECTIVES: The aims of this study were to assess depression, anxiety and stress among HCWs, to explore differences between frontline and non-frontline workers, and to investigate associated factors. METHODS: In this cross-sectional study, frontline and non-frontline HCWs were recruited from a COVID-19 screening hospital in Sri Lanka. Mental health impact was assessed using Depression, Anxiety and Stress Scale (DASS-21). Sociodemographic data and perceptions of social and occupational circumstances were gathered. Categorical variables were analyzed using Chi square and logistic regression. Odds ratios were calculated for the effect of different perceptions on psychological morbidity. RESULTS: A total of 467 HCWs participated, comprising 244 (52.2%) frontline and 223 (47.8%) non-frontline workers, with female preponderance (n=341, 77%). Prevalence of depression, anxiety and stress among HCWs were 19.5%, 20.6%, 11.8%, respectively. Non-frontline group showed a higher prevalence of depression (27% vs. 11%, p<0.001), anxiety (27% vs. 14%, p=0.001) and stress (15% vs. 8%, p=0.026). Being married, having children, living with family and higher income were associated with better psychological outcomes. Perceived lack of personal protective equipment, inadequate support from hospital authorities, greater discrimination, and lack of training to cope with the situation predicted poor mental health outcomes, and non-frontline HCWs were more likely to hold such perceptions. CONCLUSION: Addressing factors leading to negative psychological outcomes in HCWs should be a key concern during this pandemic.

Age-stratified norms for Raven's standard progressive matrices for Sri Lankan adults.

OBJECTIVE: The aim of this study was to create age-stratified norms for the Raven's Standard Progressive Matrices (SPM) for Sri Lankan adults. METHODS: A sample of 610 adults (age: 18-72 years; education: 1-19 years), underwent the 60-item version of the SPM under individual supervision of a test administrator. The sample was stratified into 5-year age bands, and the norms are presented as percentile tables and percentile curves. RESULTS: The age-related changes were more accurately predicted by a curvilinear model (overall R2 = 0.961) than a linear regression model (R2 = 0.639). The SPM norms are presented as age-stratified percentile tables, as well as sex-, age- and education-adjusted multiple regression equations. The highest percentiles in the younger end of the age spectrum showed a ceiling effect. In the context of age-stratified US (1993) and British (1992) norms, older individuals in the Sri Lankan sample scored much lower than their Western counterparts. However, the difference narrowed in the younger age bands, showing no difference among the 18-to-22-year age bands in the three countries. CONCLUSIONS: This age-by-country interaction can be partly explained by poorer education in the older individuals in the present sample compared to those in the US and UK standardization samples. SPM norms presented in this paper fill a hiatus in assessment of general intellectual ability in Sri Lankan adults. Given that Sri Lanka improves its educational, socioeconomic and health standards faster than the nations who have already reached higher standards, these norms would require re-standardization in the coming decades.

Prevalence of Suicidal Behavior Among Students in South-East Asia: A Systematic Review and Meta-Analysis.

OBJECTIVES: Estimation of rates of suicidal behaviors (ideation, plan, and attempt) would help to understand the burden and prioritize prevention strategies. However, no attempt to assess suicidal behavior among students was identified in South-East Asia (SEA). We aimed to assess the prevalence of suicidal behavior (ideation, plan, and attempt) among students in SEA. METHODS: We followed PRISMA 2020 guidelines and registered the protocol in PROSPERO (CRD42022353438). We searched in Medline, Embase, and PsycINFO and performed meta-analyses to pool the lifetime, 1-year, and point prevalence rates for suicidal ideation, plans, and attempts. We considered the duration of a month for point prevalence. RESULTS: The search identified 40 separate populations from which 46 were included in the analyses, as some studies included samples from multiple countries. The pooled prevalence of suicidal ideation was 17.4% (confidence interval [95% CI], 12.4%-23.9%) for lifetime, 9.33% (95% CI, 7.2%-12%) for the past year, and 4.8% (95% CI, 3.6%-6.4%) for the present time. The pooled prevalence of suicide plans was 9% (95% CI, 6.2%-12.9%) for lifetime, 7.3% (95% CI, 5.1%-10.3%) for the past year, and 2.3% (95% CI, 0.8%-6.7%) for the present time. The pooled prevalence of suicide attempts was 5.2% (95% CI, 3.5%-7.8%) for lifetime and 4.5% (95% CI, 3.4%-5.8%) for the past year. Higher rates of suicide attempts in the lifetime were noted in Nepal (10%) and Bangladesh (9%), while lower rates were reported in India (4%) and Indonesia (5%). CONCLUSIONS: Suicidal behaviors are a common phenomenon among students in the SEA region. These findings call for integrated, multisectoral efforts to prevent suicidal behaviors in this group.

Electroconvulsive therapy in South Asia: Past, present, and future.

The practice of electroconvulsive therapy (ECT) varies both between and within countries. We aimed to review historical and current trends in ECT practices, perceptions, and legislations in South Asia, a region with a high burden of mental illness and suicide. We searched MEDLINE (PubMed) and Google Scholar databases for relevant literature on ECT from each country. Additionally, a team of country-specific investigators performed supplemental searches and contacted key country contacts for relevant information. Relevant data were abstracted under the following headings: ECT practices, perceptions, and legislations. Knowledge gaps and research priorities were synthesized. Modified bitemporal ECT, delivered using brief pulse devices, was most commonly offered across institutions. Schizophrenia, not affective illness, was the most common indication. Electroencephalographic monitoring of seizures was rarely practiced. Thiopentone or propofol was preferred for anesthetic induction, while the favored muscle relaxant was succinylcholine. In India and Sri Lanka, perceptions about ECT were largely favorable; not so in Pakistan and Nepal. Only India and Pakistan had laws that governed any aspect of ECT practice; ECT practice guidelines were available only in India. There is a lack of research on efficacy, ECT in special populations, continuation ECT practices, and interventions to improve ECT-related perceptions. Most regional institutions offered modified brief-pulse ECT, and schizophrenia was the most common indication. Knowledge of and attitude towards ECT varied between countries. There is a need to develop a regional ECT consortium to facilitate uniform training, advocacy efforts, and the development of regional practice guidelines.

Historical developments, hotspots, and trends in tardive dyskinesia research: a scientometric analysis of 54 years of publications.

Background: Since being recognized as an important drug-induced clinical entity during the 1960s, tardive dyskinesia (TD) has generated an extensive body of research seeking to understand its clinical characteristics, epidemiology, pathophysiology and management. Modern scientometric approaches allow interactive visualization of large bodies of literature to identify trends and hotspots within knowledge domains. This study thus aimed to provide a comprehensive scientometric review of the TD literature. Methods: Web of Science was searched for articles, reviews, editorials and letters with the term "tardive dyskinesia" in the title, abstract, or keywords through 12/31/2021. A total of 5,228 publications and 182,052 citations were included. Annual research output, prominent research areas, authors, affiliations and countries were summarized. VOSViewer and CiteSpace were used for bibliometric mapping and co-citation analysis. Structural and temporal metrics were used to identify key publications in the network. Results: TD-related publications peaked in the 1990s, gradually declined after 2004, and showed a further small increase after 2015. The most prolific authors were Kane JM, Lieberman JA, and Jeste DV overall (1968-2021), and Zhang XY, Correll CU and Remington G in the last decade (2012-2021). The most prolific journal was the Journal of Clinical Psychiatry overall, and the Journal of Psychopharmacology in the last decade. Knowledge clusters in the 1960-1970s dealt with clinical and pharmacological characterization of TD. In the 1980s, epidemiology, clinical TD assessment, cognitive dysfunction and animal models predominated. During the 1990s, research diverged into pathophysiological studies, especially oxidative stress, and clinical trials on atypical antipsychotics, with a focus on clozapine and bipolar disorder. In the 1990-2000s, pharmacogenetics emerged. More recent clusters include serotonergic receptors, dopamine-supersensitivity psychosis, primary motor abnormalities of schizophrenia, epidemiology/meta-analyses, and advances in TD treatment, particularly vesicular monoamine transporter-2 inhibitors since 2017. Conclusion: This scientometric review visualized the evolution of scientific knowledge on TD over more than five decades. These findings will be useful for researchers to find relevant literature when writing scientific articles, choosing appropriate journals, finding collaborators or mentors for research, and to understand the historical developments and emerging trends in TD research.

Trait Mindfulness, Compassion, and Stigma Towards Patients with Mental Illness: A Study Among Nurses in Sri Lanka.

Objectives: Stigma towards persons with mental illness is widespread. Mindfulness may protect against stigma by cultivating accepting attitudes, non-reactivity, and prosocial emotions. This study aimed to assess whether higher trait mindfulness among nurses was linked to lower stigma towards psychiatric patients, and whether compassion mediated this relationship. Method: In this cross-sectional study among nurses in four tertiary care hospitals in Sri Lanka, stigma towards psychiatric patients was assessed using the Attribution Questionnaire (AQ-9), which assesses nine separate domains of stigma. The 20-item Six-Facet Mindfulness Questionnaire and the 5-item Santa Clara Brief Compassion Scale were used to assess mindfulness and compassion, respectively. Correlations among these variables were explored. Mediation analyses were performed. Results: A total of 405 nurses (90.6% female, mean age = 39.6 years) participated in the study. Those with higher trait mindfulness were more likely to believe they would help a person with mental illness, and less likely to believe a person with mental illness should be avoided or segregated from the society. Compassion was inversely correlated with avoidance and anger, and positively correlated with pity, helping, and coercion domains. Trait mindfulness was positively correlated with compassion. Mediation models revealed that compassion partially mediated the effects of trait mindfulness on helping and avoidance. Facet-level analyses revealed significant effects of describing, non-reactivity, and observing on several stigma domains mediated through compassion. Conclusions: Trait mindfulness among nurses appears to have a direct buffering effect against several domains of stigma towards psychiatric patients and significant indirect effects through compassion, albeit with small effect sizes. Preregistration: This study is not pre-registered.

Prevalence of suicidal behaviour among students living in Muslim-majority countries: systematic review and meta-analysis.

BACKGROUND: Assessing suicidal behaviours among students would help to understand the burden and enhance suicide prevention. AIMS: We aimed to determine the prevalence of suicidal behaviour among students living in Muslim-majority countries. METHOD: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search was conducted in Medline, EMBASE and PsycINFO. Meta-analyses were performed to pool the lifetime, 1-year and point prevalence rates for suicidal ideation, plans and attempts. RESULTS: From 80 studies, 98 separate samples were included in this analysis. The majority (n = 49) were from the Eastern Mediterranean, and 61 samples were of university students. The pooled prevalence of suicidal ideation was 21.9% (95% CI 17.4%-27.1%) for lifetime, 13.4% (95% CI 11.1%-16.1%) for the past year and 6.4% (95% CI 4.5%-9%) for current. The pooled prevalence of suicide plans was 6.4% (95% CI 3.7%-11%) for lifetime, 10.7% (95% CI 9.1%-12.4%) for the past year and 4.1% (95% CI 2.7%-6.2%) for current. The pooled prevalence of suicide attempts was 6.6% (95% CI 5.4%-8%) for lifetime and 4.9% (95% CI 3.6%-6.5%) for the past year. The lifetime prevalence of suicidal ideation was highest (46.2%) in South-East Asia, but the 12-month prevalence was highest (16.8%) in the Eastern Mediterranean. CONCLUSIONS: The study revealed notably high rates of suicidal behaviours among students living in Muslim-majority countries. However, the quality of studies, differences in regional and cultural factors, stages of studentship and methods of measurement should be considered when generalising the study results.

Global trends of machine learning applications in psychiatric research over 30 years: A bibliometric analysis.

This bibliometric analysis aimed to identify active research areas and trends in machine learning applications within the psychiatric literature. An exponential growth in the number of related publications indexed in Web of Science during the last decade was noted. Document co-citation analysis revealed 10 clusters of knowledge, which included several mental health conditions, albeit with visible structural overlap. Several influential publications in the co-citation network were identified. Keyword trends illustrated a recent shift of focus from "psychotic" to "neurotic" conditions. Despite a relative lack of literature from the developing world, a recent rise in publications from Asian countries was observed. DATA AVAILABILITY: Bibliographic data for this study were downloaded from the Web of Science. The search strategy is included in the Supplementary file.

Depression and suicidal behavior in South Asia: a systematic review and meta-analysis.

Background: Estimates of depression in suicidal behavior in South Asia would help to formulate suicide prevention strategies in the region that hasn't been assessed yet. Objectives: We aimed to systematically assess the prevalence of depression in fatal and non-fatal attempts of suicide in eight South Asian countries. Methods: We searched Medline, Embase, and PsychINFO by specific search terms to identify articles assessing depression in fatal and non-fatal attempts of suicide in South Asian countries published between 2001 and 2020. Two separate meta-analyses were conducted for fatal and non-fatal attempts. Due to the high heterogeneity of studies (96-98%), random-effects models were used to calculate pooled prevalence rates. Results: A total of 38 studies was identified from five south Asian countries (India [27], Pakistan [6], Sri Lanka [3], Nepal [1], and Bangladesh [1]). The majority of studies (n = 27) were published after 2010. Twenty-two studies reported non-fatal attempts, and sixteen reported suicide. The prevalence of depression among non-fatal attempts ranged from 14% to 78% where the pooled prevalence rate was 32.7% [95% CI 26-39.3%]. The prevalence of depression among suicides ranged from 8% to 79% where the pooled prevalence estimate was 37.3% [95% CI 26.9-47.6%]. Conclusions: This review revealed the pooled prevalence of depression among fatal and non-fatal suicidal attempts in South Asian countries, which seems to be lower when comparedto the Western countries. However, a cautious interpretation is warranted due to the heterogeneity of study methods, sample size, and measurement of depression.

Trends and Developments in Mindfulness Research over 55 Years: A Bibliometric Analysis of Publications Indexed in Web of Science.

OBJECTIVES: This study aimed to identify historical developments, active research areas, and emerging trends within scientific literature on mindfulness published so far, using bibliometric methods. We also aimed to identify prominent journals, authors, organizations, and countries in the field of mindfulness. METHODS: Articles or reviews which mention mindfulness in the title, abstract, or keywords were identified using the Web of Science. A descriptive summary of the literature was obtained from the Web of Science Analysis tool. Country collaboration, co-authorship, and keyword co-occurrence networks were visualized using VOSviewer. CiteSpace, which uses document co-citation analysis, was used to identify emerging trends and transient patterns in the literature. RESULTS: From 1966 to 2021, 16,581 publications on mindfulness were identified. There has been an exponential growth of publications since 2006. Almost half (47%) of the publications were in psychology and about one-fifth (20.8%) in psychiatry. The most prolific journal was Mindfulness (contributing 7% of all publications) and the most prolific author was Eric L. Garland. The vast majority of publications originated from Western countries but representation from Asian countries has increased. The most frequently co-occurring keywords were meditation, depression, stress, and anxiety. Co-citation analysis of the early period (1966-2015) revealed how scholarly work on spiritual themes has inspired early mindfulness research. Recent trends (2016-2021) revealed a rising interest in mechanisms and moderators, long-term meditation, neuroscientific studies, and smartphone/online delivery of interventions. CONCLUSIONS: This comprehensive bibliometric study summarized and visualized 55 years of mindfulness research, revealing pivotal points, active research areas, and emerging trends.

Regression-based, demographically adjusted norms for Victoria Stroop Test, Digit Span, and Verbal Fluency for Sri Lankan adults.

OBJECTIVE: Lack of test norms is a major limitation in neuropsychological assessment in many non-English-speaking countries. Our objective was to generate sex-, age-, and education-adjusted, regression-based norms for three pen-and-paper-based executive function/working memory tests, viz. Victoria Stroop Test (VST), Digit Span, and Verbal Fluency, for Sinhala-Speaking Sri Lankan adults. METHOD: Six-hundred and six healthy, community-living, Sinhala-speaking adults (273 men) aged 19-83 years completed VST, Digit Span (forward and backward), and Phonemic (Sinhala phonemes "N," "P," and "S") and Category (animals and vegetables) Fluency tests. We conducted multiple linear regression analyses with sex, age, and years of education fitted as predictors to model the test outcome variables. RESULTS: Younger age was associated with better performance in all tests except in Phonemic Fluency. Longer education was associated with better performance in all outcomes except VST errors and interference. Women had a significant but small advantage over men in VST Neutral and Color Word tests, and Phonemic Fluency. We report regression equations to predict norms for the test performance measures based on sex, age, and years of education; and the test variances accounted by these factors. CONCLUSIONS: We propose demographically adjusted norms for VST, Digit Span, and Verbal Fluency for Sinhala-speaking Sri Lankans aged 19-83 years, and supplement the regression formulae with a calculator that produces predicted and standard scores. These norms would help in interpreting the results of clinical samples in the future, taking into account the variability introduced by sex, age, and education.

Suicide methods in South Asia over two decades (2001-2020).

BACKGROUND: Suicide is a global preventable public health problem. About a quarter of all suicides in the world occur in South Asia. As means restriction is an important suicide prevention strategy, gaining knowledge of the common suicide methods and their changing trends in each country and region is crucial. AIMS: We aimed to assess the suicide methods in South Asian countries over the last two decades. METHODS: A search was performed in PubMed, PubMed Central, Scopus, and Google Scholar with the search terms. Original articles of quantitative studies, published in the English language, from 2001 to 2020, with full-accessible text, that rank different methods of suicide in eight South Asian countries, were included. RESULTS: A total of 68 studies were found eligible for review. The Maximum number of studies were found from India (n = 38), followed by Bangladesh (n = 12), Pakistan (n = 9), Sri Lanka (n = 6), and Nepal (n = 3). Hanging (n = 40, 55.8%) and poisoning (n = 24, 35.3%) were the two most common suicide methods reported, in that order. Hanging followed by poisoning were the commonest suicide methods in Bangladesh, India, and Pakistan while in Sri Lanka, poisoning was the preferred method to hanging. There is a decline in suicide by poisoning and an increase in suicide by hanging in Sri Lanka, Bangladesh, and India. Although hanging is still the commonest method in Pakistan, the use of firearms is growing in recent years (2011-2020). CONCLUSIONS: There is a steady decline in the incidence of suicides by poisoning following pesticide regulations in South Asian countries. However, there is heterogeneity of study methods, probable under-reporting of suicide, and lack of robust suicide data.

Prevalence and predictors of emotional and behavioral problems among institutionalized children in Kandy District, Sri Lanka.

BACKGROUND: Child care institutions (CCIs) in Sri Lanka (SL) provide residence to over 14,000 children. These children have a high risk of developing psychological problems. However, there has been no prior scientific inquiry into mental health issues of institutionalized children in SL. OBJECTIVE: To investigate the emotional and behavioral problems of children living in CCIs in Kandy District, and to explore associated factors. PARTICIPANTS AND SETTING: Ten CCIs in Kandy District were selected and all children aged 6-18 years were recruited. METHODS: Child Behavior Checklist (6-18) -Sinhala version (CBCL-S) was filled by the caregivers, and pertinent problem scores were derived. Relevant socio-demographic data were also collected. RESULTS: A total of 259 children participated. Of them, 66.8 % were female. The mean age was 13.9 years. The average duration in care was 4.3 years. Clinical levels of behavioral problems were found in 14 % of children, whereas 7% were borderline. Externalizing problems like rule-breaking and aggression were more common (23.3 %) than internalizing problems (6.6 %). Male children exhibited more behavioral problems (p = 0.034). Present age, age on admission, duration in care, history of sexual abuse, institutional transfers and frequency of family contact were not associated with behavioral problems. CONCLUSIONS: Institutionalized children showing high levels of externalizing problems may be a reflection of disturbed psychosocial development. However, internalizing problems may not be readily recognized, partly due to the shortage of trained caregivers in SL. Educating caregivers to detect and refer children with behavioral problems to psychiatric services is recommended.

Sex-, age- and education-adjusted norms for the WHO/UCLA version of the Rey Auditory Verbal Learning Test for Sinhala-speaking Sri Lankan adults.

OBJECTIVE: The aim of this study was to create sex-, age- and education-adjusted norms for the WHO/UCLA version of the Rey Auditory Verbal Learning Test (RAVLT) for Sinhala-speaking Sri Lankan adults. METHODS: Five-hundred and sixty-one healthy, community-living adults (252 men), aged 19-83 years, and had 0-23 years of education completed the WHO/UCLA RAVLT in Sinhala language. We conducted multiple linear regression analyses with sex, age and years of education to predict RAVLT list A1-A5 individual trial scores; trials A1-A5 total learning; list B score; immediate and delayed recall and recognition trial scores; and retroactive interference. RESULTS: We report regression equations to predict RAVLT norms based on sex, age and years of education; and the test variances accounted by those variables. Accordingly, all measures, except retroactive interference had a significant age-related decline. All measures, except the recognition trial hits, significantly improved with more years of education. Women had significantly higher scores in all measures except in trial B and retroactive interference. Proactive interference, learning rate, learning over trials were not associated with sex, age or education. A confirmatory factor analysis loaded the RAVLT outcome measures into two factors: acquisition and retention. CONCLUSIONS: We report sex-, age- and education-adjusted WHO/UCLA RAVLT norms for Sinhala-speaking Sri Lankans aged 19-83 years; and supplement the regression formulae with a calculator that produces predicted and standard scores for given test participant. These norms would help clinicians accurately interpret individual test results, accounting for the variability introduced by sex, age and education.