Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention

Clinical utility of depression measures and symptoms: Implications for suicide risk assessment in high risk, resource limited youth populations

OBJECTIVE

Suicide risk for youth in resource- limited settings has been largely underrepresented in the literature and requires targeted examination of practical ways to address this growing public health concern. The present study focuses on the clinical utility of depression risk assessment tools addressing how and for whom suicide prevention intervention is most beneficial within a low-middle-income-country, high suicide risk youth sample.

METHODS

Youth who reported a previous suicide attempt versus those who did not were criterion to test the validity of depression and hopelessness symptom assessment tools. We used item analyses to identify depressive symptom endorsements that most informed youth suicide risk, which will better equip rural practitioners for targeted intervention and monitoring of youth with an already high risk for suicide.

RESULTS

Findings demonstrated that practitioners may target symptoms of social anhedonia, depressed mood, concentration disturbance, feelings of worthlessness, sleep disturbance, and fatigue for suicide prevention-intervention efforts among high-risk youth.

CONCLUSIONS

Study implications are for clinicians' use of the BDI-II and CES-D for depression symptom identification and suicide risk monitoring in settings with limited mental health infrastructure.

Determinants of mental illness and care seeking behaviours in Northern Haiti: an assessment of demographic, social, and religio-cultural factors among patients at the first mental health clinic in the region

Populations in countries such as Haiti demonstrate a high level of need for mental health care despite a lack of services and trained professionals. In addition to the dearth of biomedical services, local belief systems and explanatory models contribute to a majority of the population relying on traditional medicine as their first option for care. Using a mixed-methods approach, we aim to characterise mental illness at the first mental health clinic in the region - Sant Sante Mantal Mòn Pele (SSMMP) - by interviewing 96 patients with a demographic questionnaire as well as Anxiety, Depression, and Functionality Scales. Multivariate logistic and linear regression models were conducted examining the impact of demographic variables on whether patients believed their illness was caused by sent spirits or previously visited a Vodou priest for treatment, as well as Depression, Anxiety, and Functionality Scale scores. Factors associated with mental illness in this sample included sex, number of traumatic events, physical health status, and number of sessions attended at SSMMP. Factors which impacted traditional beliefs or practices related to mental illness included sex, age, and income.

The engaged community action for preventing suicide (ECAPS) model in Latin America: development of the ¡PEDIR! program

PURPOSE

It is estimated that someone dies by suicide every 40 s globally and that 3000 people end their lives daily. Of these deaths, 79% occur in low-resource settings. The very nature of the low-resource settings often serves as a barrier to the adoption and implementation of evidence-based suicide prevention models that have demonstrated success in high-resource countries. As such rates of suicide continue to increase, the workforce of trained mental health providers equipped to effectively engage, assess, and treat individuals struggling with suicidal thoughts and behaviors remains relatively stagnant. This paper aims to illustrate the implementation of the Engaged Community Action for Preventing Suicide (ECAPS) model as a means of developing a culturally relevant and responsive model of suicide prevention that is acceptable and sustainable in low-resource settings.

METHODS

University faculty and staff (n=34) and psychology students (n=25), and community-based mental health providers (n=41) providing mental health services to at-risk individuals in highly vulnerable communities in Lima, Peru participated in the implementation of ECAPS process.

RESULTS

The resulting program, ¡PEDIR!, demonstrates the acceptability, feasibility, and effectiveness of the ECAPS model.

CONCLUSION

The ECAPS model is a feasible and effective framework for use in low-resource settings to guide the development of a culturally relevant community-level intervention to address the systemic, societal, and individual level factors that serve as barriers to suicide prevention.

Building interventions when distress is under debate: a case study from Appalachia

Scholarship on idioms of distress has emphasized cross-cultural variation, but devoted less attention to intra-cultural variation-specifically, how the legitimacy of distress may vary according to the context in which it is expressed, social position, and interaction with medical categories of distress. This variation can pose challenges for interventionists seeking to establish culturally acceptable ways of identifying distress and creating relevant resources for recovery. We describe efforts over three years (2014-2016) to identify and adapt a culturally appropriate evidence-based intervention for depressed rural Appalachian women. Though the prevalence of depression among rural women is high, limited services and social barriers restrict treatment access. Formative research revealed varied understandings of distress. Depression was (a) medicalized as a treatable condition, (b) stigmatized as mental illness, (c) accepted as a non-pathological reaction to regional poverty and gendered caregiving responsibilities, (d) rejected as a worthy justification for seeking individual care, and (e) less represented in comparison to other competing forms of distress (i.e., multiple morbidities, family members' distress). In a small pilot trial, we applied an implementation science perspective to identify and implement appropriate evidence-based programming for the context. We outline how we reached Appalachian women despite these diverse understandings of depression and established a flexible medicalization of depression that enabled us to legitimize care-seeking, work with varied rural healthcare professionals, and engender culturally relevant support. Our adaptation and implementation of the concept of "mental health recovery" enabled the development of programming that furthered non-pathological communicative distress while resisting the normalization that silences women in the context of deep health disparities.

Helping or Heightening Vulnerability? Midwives as Arbiters of Risk for Women Experiencing Self-Directed Violence in Urban Sri Lanka

The response of midwives to women engaging in self-directed violence (SDV) may affect women's care and outcomes. The author explored midwives' understanding of SDV through semi-structured focus groups and in-depth interviews with 11 Public Health Midwives in urban Sri Lanka. Thematic analysis identified four key themes: (a) perceived dimensions of women's risk and vulnerability to SDV, (b) midwives as arbiters of risk, (c) representations of women engaging in SDV, and (d) midwives' perceived capacity to respond. Given their proximity to communities, trustworthiness as sites of disclosure, and respectability as women and guardians of ideal womanhood in Sri Lankan society, midwives occupy a powerful position in the health system through which to alleviate or reinforce women's risk to SDV. Yet, investment in developing their skills and role to respond to the growing phenomenon of SDV among women in Sri Lanka must consider the context within which midwives assess and select their responses.

Clinical risk factors among youth at high risk for suicide in South Africa and Guyana

INTRODUCTION

Suicide is the second leading cause of death among youth worldwide, but low- and middle-income countries (LMICs) account for 78% of all suicides. The LMICs South Africa and Guyana rank high in the global suicide rates. To better understand and prevent suicide among the youth, the present study targets youths at high risk for suicide, in an LMIC, to contextually and representatively identify clinical risk factors for suicide.

METHODS

One hundred-ninety youths, aged 11-21, separated from biological parents at the time of assessment, in South Africa and Guyana, were administered the Child Behavior Checklist and Behavior Assessment System for Children to assess clinical symptoms. The youths were asked about current suicide ideation and previous attempt(s). Self-report responses to clinical items yielded scale scores for depression, social stress, atypicality, somatization, anxiety, and ADHD. Using an integrative data analytic technique, clinical scale scores were standardized and used to predict suicidal behaviors in a binary logistic regression analysis.

RESULTS

Approximately 22% of Black South African youths and 60% of Guyanese youths endorsed suicide ideation and attempt or suicide attempt only. In fully adjusted analyses, the odds of atypicality and somatization were 1.96 and 1.67 times greater among the youths who endorsed suicidal ideation when compared with those who did not (p < .04). Youth social stress was significantly associated with the suicide attempt, controlling for model covariates (odds ratio [OR], 1.88, p = .05). Gender moderated the effect of somatization on youth suicide.

CONCLUSION

Our results contextualize how social stress, atypicality, and somatization relate to LMIC youth suicide. Further study on high-risk samples will contribute to generalizable suicide-prevention models.

Vodou's role in Haitian mental health

This paper gives an overview of Vodou's history in Haiti and how Vodou informs Haitian mental health interventions.

Beyond bare bones: critical, theoretically engaged qualitative research in public health

While qualitative inquiry has been a part of the Canadian Journal of Public Health (CJPH) for many years, CJPH does not yet have the reputation as a home for qualitative research that has a critical focus and that is cqqqonversant with contemporary developments in social theory and qualitative methodology. This paper describes efforts to establish CJPH as a welcoming home for critical, theoretically engaged qualitative research in public health. The paper introduces the Special Section that heralds the forward vision for qualitative research at CJPH. We specify what we mean by critical, theoretically engaged qualitative research and make the case for its significance for public health research and practice. We describe changes made in how qualitative manuscript submissions are handled at CJPH and highlight the contribution to public health scholarship made by the articles that comprise the Special Section. We issue an invitation to the public health community to support and participate in our vision to enhance critical, theoretically informed qualitative research in public health.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

Mental Health Diagnostic Frameworks, Imputed Causes of Mental Illness, and Alternative Treatments in Northern Tanzania: Exploring Mental Health Providers' Perspectives

In Tanzania, a nation with a large mental health treatment gap, local stakeholders' perspectives are critical for informing effective treatment. The practice-based perspectives of mental health providers may be particularly instructive. Existing foundational literature on the professional population in this region is scarce. We conducted semi-structured interviews with 29 mental health providers in northern Tanzania. Interviews focused on three topics: use of international diagnostic frameworks for mental illness, beliefs about causes of mental health concerns, and alternative treatments sought by clients. Interview data were coded and analyzed using consensual qualitative research and the constant comparative method. Usage of diagnostic frameworks varied widely. Providers believed frameworks accurately described many patients but neglected somatic symptoms and contained diagnoses that they had never witnessed. Providers described supernatural and spiritual attributions of mental illness as substantially impacting treatment decisions. Other notable attributions included physical illness, drug/alcohol use, and heredity. Providers reported their clients routinely sought treatment from traditional and spiritual healers prior to seeking care in the formal health system. This study builds a foundation for the ongoing development of the mental health system in northern Tanzania. Findings also support exploration of integrative models of care and task-shifting to incorporate traditional and spiritual beliefs.

A mobile clinic approach to the delivery of community-based mental health services in rural Haiti

This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic’s first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic’s lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.

Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster

AIM

To describe the physical, psychological and sexual violence among internally displaced adolescent girls following the 2010 Haiti earthquake and related risk factors, health concerns and cultural norms.

BACKGROUND

Thousands of adolescents were displaced following the earthquake, leaving them vulnerable to abuse and violence. Displaced survivors are disproportionately vulnerable to violence after natural and man-made disasters.

DESIGN

A descriptive-correlational design was used to: (1) describe the extent of violence, health risks and concerns in the displaced adolescent girls; and (2) identify correlations in the strength and magnitude of relationships between selected variables including demographics, risk factors and cultural tolerance of violence.

METHODS

Data were collected from participants using computer-assisted self-interviews between 2011-2013 including demographics, pre- and post-earthquake violence, perpetrators, risk factors and health consequences. Analysis included frequency, logistic regression and multiple regression.

RESULTS/FINDINGS

A majority reported physical, psychological, or sexual abuse both pre- (59%) and post- (64.1%) earthquake. Pre-earthquake, abused adolescents reported the perpetrator as a boyfriend (50%) or family member (30%). Post-earthquake, 20.5% of physical abuse perpetrators were family members. Pre- and post-earthquake physical and sexual abuse did not change. The risk of being sexually abused post-earthquake increased after controlling for age and education.

CONCLUSION

Displaced adolescent girls reported similar rates of physical and sexual abuse pre- and post-earthquake. These findings show the importance of preventive policies for adolescent girls in disaster situations in countries with low resources. Social and cultural change is critically needed since abuse was at an unacceptably high rate prior to the earthquake.

Suicide surveillance and health systems in Nepal: a qualitative and social network analysis

BACKGROUND

Despite increasing recognition of the high burden of suicide deaths in low- and middle-income countries, there is wide variability in the type and quality of data collected and reported for suspected suicide deaths. Suicide data are filtered through reporting systems shaped by social, cultural, legal, and medical institutions. Lack of systematic reporting may underestimate public health needs or contribute to misallocation of resources to groups most at risk.

METHODS

The goal of this study was to explore how institutional structures, cultural perspectives on suicide, and perceived criminality of self-harm influence the type and quality of suicide statistics, using Nepal as an example because of its purported high rate of suicide in the public health literature. Official documentation and reporting networks drawn by police, policy makers, and health officials were analyzed. Thirty-six stakeholders involved in various levels of the death reporting systems in Nepal participated in in-depth interviews and an innovative drawn surveillance system elicitation task.

RESULTS

Content analysis and social network analysis revealed large variation across the participants perceived networks, where some networks were linear pathways dominated by a single institution (police or community) with few nodes involved in data transmission, while others were complex and communicative. Network analysis demonstrated that police institutions controlled the majority of suicide information collection and reporting, whereas health and community institutions were only peripherally involved. Both health workers and policy makers reported that legal codes criminalizing suicide impaired documentation, reporting, and care provision. However, legal professionals and law review revealed that attempting suicide is not a crime punishable by incarceration. Another limitation of current reporting was the lack of attention to male suicide.

CONCLUSIONS

Establishment and implementation of national suicide prevention strategies will not be possible without reliable statistics and comprehensive standardized reporting practices. The case of Nepal points to the need for collaborative reporting and accountability shared between law enforcement, administrative, and health sectors. Awareness of legal codes among health workers, in particular dispelling myths of suicide's illegality, is crucial to improve mental health services and reporting practices.

Suicide Attempts and Deaths in Sofala, Mozambique, From 2011 to 2014

BACKGROUND

Mozambique was recently estimated to have the highest suicide rate in Africa.

AIMS

To fill a knowledge gap on suicide attempts and deaths in Mozambique.

METHOD

We reviewed a census of 898 emergency psychiatric consultations from March 2013 to July 2014 and 1,173 violent death autopsy records from June 2011 to August 2014 at Beira Central Hospital in Sofala, Mozambique.

RESULTS

In all, 18.0% of emergency psychiatric consultations were suicide attempts. Females were disproportionately represented (68.3%, p < .001), and the mean age was 26.8 years. Rat poison was used in 66% of attempts, followed by unspecified methods (19.8%), and unspecified poisoning (6.8%). Of the violent death autopsies, 10% were suicides. Suicide deaths were more likely to be male (67.3%, p < .001), and the mean age was 30.8 years. Common methods were hanging (43.2%), unspecified substance (28.0%), or rat poison (26.3%). Common places of death were the hospital or hospital transit (46.4%) and the household (35.7%). Female suicide deaths more often involved toxic substances and males more often employed hanging.

CONCLUSION

Females more often present with suicide attempts, but deaths due to suicide are more frequent among males. Females more often use toxic substances, whereas males more often use lethal methods, such as hanging. Policies to reduce the availability or toxicity of rat poison should be considered.

Authorship in global mental health research: recommendations for collaborative approaches to writing and publishing

BACKGROUND

Collaborations among researchers, clinicians, and individuals with mental illness from high-income countries (HICs) and low- and middle-income countries (LMICs) are crucial to produce research, interventions, and policies that are relevant, feasible, and ethical. However, global mental health and cultural psychiatry research publications have been dominated by HIC investigators.

OBJECTIVE

The aim of this review was to present recommendations for collaborative writing with a focus on early career investigators researchers in HICs and LMICs.

METHODS

A workshop was conducted with HIC and LMIC investigators in Nepal to discuss lessons learned for collaborative writing. The researchers had experience in cross-cultural psychiatric epidemiology, health services research, randomized controlled trials, and projects with war and disaster-affected populations in complex humanitarian emergencies including child soldiers and refugees. Additional lessons learned were contributed from researchers engaged in similar collaborations in Haiti.

FINDINGS

A step-by-step process for collaborative writing was developed.

CONCLUSIONS

HIC and LMIC writing collaborations will encourage accurate, ethical, and contextually grounded publications to foster understanding and facilitate reduction of the global burden of mental illness.

Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal

BACKGROUND

Despite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. Self-report screening tools, such as the Patient Health Questionnaire (PHQ-9), require modification for low literacy populations and to assure cultural and clinical validity. An alternative approach is to employ idioms of distress that are locally salient, but these are not synonymous with psychiatric categories. Therefore, our objectives were to evaluate the validity of the PHQ-9, assess the added value of using idioms of distress, and develop an algorithm for depression detection in primary care.

METHODS

We conducted a transcultural translation of the PHQ-9 in Nepal using qualitative methods to achieve semantic, content, technical, and criterion equivalence. Researchers administered the Nepali PHQ-9 to randomly selected patients in a rural primary health care center. Trained psychosocial counselors administered a validated Nepali depression module of the Composite International Diagnostic Interview (CIDI) to validate the Nepali PHQ-9. Patients were also assessed for local idioms of distress including heart-mind problems (Nepali, manko samasya).

RESULTS

Among 125 primary care patients, 17 (14 %) were positive for a major depressive episode in the prior 2 weeks based on CIDI administration. With a Nepali PHQ-9 cutoff ≥ 10: sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) =0.42, negative predictive value (NPV) =0.99, positive likelihood ratio = 4.62, and negative likelihood ratio = 0.07. For heart-mind problems: sensitivity = 0.94, specificity = 0.27, PPV = 0.17, NPV = 0.97. With an algorithm comprising two screening questions (1. presence of heart-mind problems and 2. function impairment due to heart-mind problems) to determine who should receive the full PHQ-9, the number of patients requiring administration of the PHQ-9 could be reduced by 50 %, PHQ-9 false positives would be reduced by 18 %, and 88 % of patients with depression would be correctly identified.

CONCLUSION

Combining idioms of distress with a transculturally-translated depression screener increases efficiency and maintains accuracy for high levels of detection. The algorithm reduces the time needed for primary healthcare staff to verbally administer the tool for patients with limited literacy. The burden of false positives is comparable to rates in high-income countries and is a limitation for universal primary care screening.

Task sharing in rural Haiti: Qualitative assessment of a brief, structured training with and without apprenticeship supervision for community health workers

Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.

Reflechi twòp--thinking too much: description of a cultural syndrome in Haiti's Central Plateau

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti's Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with "thinking too much" have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. "Thinking too much" is associated with 8 times greater odds of suicidal ideation. Untreated "thinking too much" is sometimes perceived to lead to psychosis. Recognizing and understanding "thinking too much" may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti's Central Plateau.

Sociocultural context of suicidal behaviour in the sundarban region of India

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their "intention to die," and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.