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Kim Y, Rimal D, K C A, Shrestha S, Luitel NP, Prigerson HG, Tol WA, Surkan PJ. Understanding Nepali widows' experiences for the adaptation of an instrument to assess Prolonged Grief Disorder. Transcult Psychiatry 2023; 60:891-904. [PMID: 33351725 DOI: 10.1177/1363461520949005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The experience of grief varies across different cultures and contexts. Women in Nepal who lose their husbands confront discrimination, social isolation, and abuse that influence their experience of grief. Through eight focus group discussions with Nepali widows, we elicited socially sanctioned grief reactions and local idioms used to describe common cognitive, behavioral, and emotional symptoms of grief. Accordingly, modifications to an existing instrument for Prolonged Grief Disorder, the PG-13, are suggested to capture grief symptoms as experienced by Nepali widows. Items in the PG-13 were translated to colloquial Nepali and adapted to maintain comprehensibility, acceptability, relevance, and completeness. Based on the grief-related issues reported in the focus group discussions, the addition of five new items and a new criterion to capture symptoms related to social discrimination are proposed. Widows perceived elevated symptoms one year after the loss to be problematic. It is thus recommended that the duration criterion in the original PG-13 be adjusted from at least six months to at least one year after the loss. These proposed modifications to the instrument should be validated through future psychometric testing.
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Affiliation(s)
- Yoona Kim
- Bloomberg School of Public Health, Johns Hopkins University
| | | | - Angela K C
- Bloomberg School of Public Health, Johns Hopkins University
| | | | | | | | - Wietse A Tol
- Section of Global Health, Department of Public Health, University of Copenhagen
- Peter C. Alderman Program for Global Mental Health at HealthRight International
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Somasundaram D, Jayasuriya R, Perera R, Thamotharampillai U, Wickremasinghe R, Tay AK. Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka. BJPsych Open 2023; 9:e180. [PMID: 37818719 PMCID: PMC10594160 DOI: 10.1192/bjo.2023.563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 08/15/2023] [Accepted: 08/15/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict. AIMS To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war. METHOD In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods. RESULTS Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population. CONCLUSIONS Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.
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Affiliation(s)
| | - Rohan Jayasuriya
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Ruwanthi Perera
- Department of Rogavijnana, Faculty of Indigenous Medicine, Gampaha Wickramarachchi University of Indigenous Medicine, Yakkala, Sri Lanka
| | | | - Rajitha Wickremasinghe
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Alvin Kuowei Tay
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, Australia
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Ramaiya MK, McLean CL, Pokharel M, Thapa K, Schmidt MA, Berg M, Simoni JM, Rao D, Kohrt BA. Feasibility and Acceptability of a School-Based Emotion Regulation Prevention Intervention (READY-Nepal) for Secondary School Students in Post-Earthquake Nepal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114497. [PMID: 36361372 PMCID: PMC9655041 DOI: 10.3390/ijerph192114497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Child and adolescent mental health problems are major contributors to the global burden of disease in low- and middle-income country (LMIC) settings. To advance the evidence base for adolescent mental health interventions in LMICs, we evaluated the feasibility and acceptability of a school-based emotion regulation prevention intervention (READY-Nepal) for adolescents who had a recent exposure to a humanitarian disaster. METHODS A mixed-method, non-randomized controlled trial was conducted with Nepali secondary school students in one heavily affected post-earthquake district. Students (N = 102; aged 13 to 17 years) were enrolled in the intervention (n = 42) and waitlist control (n = 60) conditions. Feasibility and acceptability were examined via attendance, and by qualitative interviews with a subset of students (n = 15), teachers (n = 2), and caregivers (n = 3). Preliminary efficacy was examined on primary outcome (emotion regulation) and secondary outcomes (anxiety symptoms, posttraumatic stress symptoms, functional impairment, resilience, coping skills), which were measured at baseline and post-intervention (four weeks). RESULTS Delivering the intervention was feasible and acceptable, as demonstrated by low dropout (8%) and high program attendance (6.7 of 8 sessions). Qualitative data suggested high uptake of anger regulation skills, but lower uptake of mindfulness skills. Despite this, there were no significant differences by condition on primary or secondary outcomes at four-week follow-up. Students provided suggestions for improvement of the program. CONCLUSION Further research on longitudinal outcome measurement, use of alternatives to retrospective self-report data, and rigorous development of culturally grounded models of emotion regulation is necessary to explore the utility of school-based emotion regulation interventions in Nepal and other LMICs.
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Affiliation(s)
- Megan K. Ramaiya
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA 94143, USA
- Correspondence:
| | - Caitlin L. McLean
- VA San Diego Healthcare System, University of California, San Diego, CA 92161, USA
| | - Manjila Pokharel
- Transcultural Psychosocial Organization Nepal, Kathmandu 44600, Nepal
| | - Kiran Thapa
- College of Public Health, University of Georgia, Athens, GA 30602, USA
| | - M. Andi Schmidt
- School of Graduate Psychology, Pacific University Oregon, Forest Grove, OR 97116, USA
| | - Martha Berg
- Department of Psychology, University of Michigan-Ann Arbor, Ann Arbor, MI 48103, USA
| | - Jane M. Simoni
- Department of Psychology, University of Washington, Seattle, WA 98195, USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
| | - Brandon A. Kohrt
- Division of Global Mental Health, George Washington University, Washington, DC 20052, USA
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Frounfelker RL, Mishra T, Carroll A, Brennan RT, Gautam B, Ali EAA, Betancourt TS. Past trauma, resettlement stress, and mental health of older Bhutanese with a refugee life experience. Aging Ment Health 2022; 26:2149-2158. [PMID: 34396853 PMCID: PMC9386683 DOI: 10.1080/13607863.2021.1963947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/30/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Older displaced persons often receive limited attention from aid organizations, policy-makers and service providers in countries of resettlement. The objective of this study is to identify the relationship between experiencing traumatic events and stressors prior to resettlement, current resettlement stressors, social support, and mental health of older Bhutanese with a refugee life experience. METHOD Study participants were 190 older Bhutanese with a refugee life experience living in a metropolitan area in New England (US) and Ontario (Canada). We used structural equation modeling to determine the association between traumatic and stressful events in Bhutan and Nepal, current resettlement stressors, and symptoms of anxiety and depression, as measured by the GAD-7 and PHQ-9. We assessed the role of social support as an effect modifier in the relationship between these variables. RESULTS Surviving torture was associated with anxiety (p=.006), and experiencing threats to physical wellbeing in Nepal was associated with both anxiety (p=.003) and depression (p=.002). The relationship between physical threats in Nepal and current mental health were partially mediated by resettlement stressors. Social support moderated the relationship between trauma, stress, and mental health. CONCLUSION Both past traumas and current resettlement stressors contribute to the current psychosocial functioning of older Bhutanese with a refugee life experience. Based on our findings, social support is critical in promoting mental health in this population.
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Affiliation(s)
- Rochelle L Frounfelker
- Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Tej Mishra
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Alexa Carroll
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Robert T Brennan
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
- Women's Study Research Center, Brandeis University, Waltham, MA, USA
| | - Bhuwan Gautam
- Bhutanese Society of Western Massachusetts, Inc., Springfield, MA, USA
| | - Eman Abdullahi Alas Ali
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Theresa S Betancourt
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
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Defining culturally compelling mental health interventions: A qualitative study of perspectives on adolescent depression in Lagos, Nigeria. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Wahid SS, Sarker M, Arafat ASME, Apu AR, Kohrt BA. Tension and Other Idioms of Distress Among Slum Dwelling Young Men: A Qualitative Study of Depression in Urban Bangladesh. Cult Med Psychiatry 2022; 46:531-563. [PMID: 34328610 PMCID: PMC9034992 DOI: 10.1007/s11013-021-09735-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
In low- and middle-income countries (LMIC) it is vital to understand acceptable, comprehensive, and culturally appropriate ways of communicating about mental distress. Diagnostic terminology is rarely used, may be stigmatizing, and is subject to misinterpretation. Local terms, such as idioms of distress, can improve mental health literacy and service delivery. Our objective was to examine lived experience and coping connected to distress and depression in an under-researched population: young men from LMIC urban slums. We conducted 60 qualitative interviews with men (ages 18-29) in Bhashantek slum, Bangladesh. Themes were generated using thematic analysis and grounded theory techniques. The heart-mind (mon), mentality (manoshikota), mood (mejaj), head (matha or "brain"), and body (shorir) comprised the self-concept, and were related to sadness, hopelessness, anger, worry, and mental illness. The English word "tension" was the central idiom of distress. "Tension" existed on a continuum, from mild distress or motivational anxiety, to moderate distress including rumination and somatic complaints, to severe psychopathology including anhedonia and suicidality. Respondents connected "tension" to burnout experiences and mental illness which was summarized in an ethnopsychological model. These findings can inform culturally sensitive measurement tools and interventions that are acceptable to the community, potentially increasing engagement and enhancing therapeutic outcomes.
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Affiliation(s)
- Syed Shabab Wahid
- Department of Global Health, George Washington University, Washington, DC, USA. .,Division of Global Mental Health, George Washington University, Washington, DC, USA.
| | - Malabika Sarker
- BRAC James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh ,Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | - Arifur Rahman Apu
- BRAC James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Brandon A. Kohrt
- Department of Global Health, George Washington University, Washington, DC USA ,Division of Global Mental Health, George Washington University, Washington, DC USA
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A cross-cultural interpersonal model of adolescent depression: A qualitative study in rural Nepal. Soc Sci Med 2021; 270:113623. [PMID: 33461033 PMCID: PMC7895817 DOI: 10.1016/j.socscimed.2020.113623] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/25/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
Most cross-cultural qualitative research on depression has been descriptive, documenting symptoms and explanatory models. There is a lack of qualitative research testing theoretical models of depression. The interpersonal model conceptualises grief, interpersonal disputes, role transitions and social isolation as the context in which depression develops and is the basis of interpersonal therapy (IPT), which is increasingly used in cross-cultural settings to treat depression. We aimed to qualitatively evaluate to what extent the interpersonal model can explain adolescent depression in Nepal. Data were collected between December 2018 and April 2019 and comprised transcripts from 126 participants: 25 semi-structured interviews with depressed adolescents aged 13–18; four focus group discussions with adolescents (N = 38), four with parents/caregivers (N = 39), and two with teachers (N = 17); and seven semi-structured interviews with health and non-governmental organisation workers. We coded data using an analytical framework comprising deductive codes representing key concepts from the interpersonal model of depression and IPT, including principles, techniques and strategies. Participants mainly related depression to interpersonal problem areas of grief, dispute, role transition and social isolation. Interpersonal disputes were common, and for many adolescents this involved parental physical and emotional abuse. Although role transitions were common few adolescents grieved loss of the prior role. Distress related to social isolation was evident despite close physical proximity and extensive social interaction with family and community members. Adolescents described coping strategies that were similar to strategies central to IPT, e.g. identifying helpful and unhelpful relationships and generating options and ways of managing problems. In conclusion, interpersonal problems are relevant to this population and conceptualisations align with core principles of the interpersonal model of depression. The findings highlight the importance of addressing abuse and maltreatment in depression aetiology. They also inform future cultural adaptations of IPT in Nepal and beyond, including the opportunity to integrate local coping strategies. Testing psychological models cross-culturally is important for adapting therapies. Interpersonal problems trigger depression among adolescents in Nepal. Experiences of depression align with core principles of interpersonal therapy (IPT). Few adolescents use IPT strategies to address interpersonal problems. Models of depression must incorporate poverty, migration and abuse as risk factors.
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Development of the mental health cultural adaptation and contextualization for implementation (mhCACI) procedure: a systematic framework to prepare evidence-based psychological interventions for scaling. Glob Ment Health (Camb) 2021; 8:e6. [PMID: 33996110 PMCID: PMC8082944 DOI: 10.1017/gmh.2021.5] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/11/2020] [Accepted: 01/13/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Because of the high burden of untreated mental illness in humanitarian settings and low- and middle-income countries, scaling-up effective psychological interventions require a cultural adaptation process that is feasible and acceptable. Our adaptation process incorporates changes into both content and implementation strategies, with a focus on local understandings of distress and treatment mechanisms of action. METHODS Building upon the ecological validity model, we developed a 10-step process, the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) procedure, and piloted this approach in Nepal for Group Problem Management Plus (PM+), a task-sharing intervention, proven effective for adults with psychological distress in low-resource settings. Detailed documentation tools were used to ensure rigor and transparency during the adaptation process. FINDINGS The mhCACI is a 10-step process: (1) identify mechanisms of action, (2) conduct a literature desk review for the culture and context, (3) conduct a training-of-trainers, (4) translate intervention materials, (5) conduct an expert read-through of the materials, (6) qualitative assessment of intervention population and site, (7) conduct practice rounds, (8) conduct an adaptation workshop with experts and implementers, (9) pilot test the training, supervision, and implementation, and (10) review through process evaluation. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of 'tension'; modification of recruitment procedures to assure fit; and development of a skills checklist. CONCLUSION A 10-step mhCACI process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation.
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Abstract
In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.
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Poudyal A, van Heerden A, Hagaman A, Maharjan SM, Byanjankar P, Subba P, Kohrt BA. Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal. JMIR Res Protoc 2019; 8:e14734. [PMID: 31512581 PMCID: PMC6746061 DOI: 10.2196/14734] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. OBJECTIVE This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. METHODS This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. RESULTS To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. CONCLUSIONS Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14734.
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Affiliation(s)
- Anubhuti Poudyal
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Alastair van Heerden
- Human and Social Development, Human Sciences Research Council, Pietermaritzburg, South Africa
- Medical Research Council/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley Hagaman
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, United States
| | | | | | | | - Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, Washington, DC, United States
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11
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Brown FL, Mishra T, Frounfelker RL, Bhargava E, Gautam B, Prasai A, Betancourt TS. 'Hiding their troubles': a qualitative exploration of suicide in Bhutanese refugees in the USA. Glob Ment Health (Camb) 2019; 6:e1. [PMID: 30854217 PMCID: PMC6401374 DOI: 10.1017/gmh.2018.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/25/2018] [Accepted: 10/11/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Suicide is a major global health concern. Bhutanese refugees resettled in the USA are disproportionately affected by suicide, yet little research has been conducted to identify factors contributing to this vulnerability. This study aims to investigate the issue of suicide of Bhutanese refugee communities via an in-depth qualitative, social-ecological approach. METHODS Focus groups were conducted with 83 Bhutanese refugees (adults and children), to explore the perceived causes, and risk and protective factors for suicide, at individual, family, community, and societal levels. Audio recordings were translated and transcribed, and inductive thematic analysis conducted. RESULTS Themes identified can be situated across all levels of the social-ecological model. Individual thoughts, feelings, and behaviors are only fully understood when considering past experiences, and stressors at other levels of an individual's social ecology. Shifting dynamics and conflict within the family are pervasive and challenging. Within the community, there is a high prevalence of suicide, yet major barriers to communicating with others about distress and suicidality. At the societal level, difficulties relating to acculturation, citizenship, employment and finances, language, and literacy are influential. Two themes cut across several levels of the ecosystem: loss; and isolation, exclusion, and loneliness. CONCLUSIONS This study extends on existing research and highlights the necessity for future intervention models of suicide to move beyond an individual focus, and consider factors at all levels of refugees' social-ecology. Simply focusing treatment at the individual level is not sufficient. Researchers and practitioners should strive for community-driven, culturally relevant, socio-ecological approaches for prevention and treatment.
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Affiliation(s)
- F. L. Brown
- War Child Holland, Amsterdam, The Netherlands
- Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - T. Mishra
- Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - R. L. Frounfelker
- Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- SHERPA Research Centre, CIUSS Centre-Ouest de l-ile de Montreal, Montreal, Canada
- McGill University, Montreal, Canada
| | | | - B. Gautam
- Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Chase LE, Sapkota RP, Crafa D, Kirmayer LJ. Culture and mental health in Nepal: an interdisciplinary scoping review. Glob Ment Health (Camb) 2018; 5:e36. [PMID: 30455971 PMCID: PMC6236213 DOI: 10.1017/gmh.2018.27] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/19/2018] [Accepted: 08/22/2018] [Indexed: 12/16/2022] Open
Abstract
Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scoping review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.
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Affiliation(s)
- L. E. Chase
- McGill University - Global Mental Health Program, Montreal, Quebec, Canada
| | - R. P. Sapkota
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada
| | - D. Crafa
- Integrated Program in Neuroscience, McGill University, Montreal, Canada
| | - L. J. Kirmayer
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada
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Hagaman AK, Khadka S, Wutich A, Lohani S, Kohrt BA. Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths. Cult Med Psychiatry 2018; 42:704-734. [PMID: 29881930 PMCID: PMC6286252 DOI: 10.1007/s11013-018-9585-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Ashley K Hagaman
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W Franklin St, Chapel Hill, NC, 27516, USA.
| | - Seema Khadka
- Transcultural Psychosocial Organization Nepal, Research Department, Kathmandu, Nepal
| | - Amber Wutich
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA
| | - Shyam Lohani
- Nobel College, Pokhara University, Kathmandu, Nepal
| | - Brandon A Kohrt
- Department of Psychiatry, George Washington University, Washington, DC, USA
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Ramaiya MK, Fiorillo D, Regmi U, Robins CJ, Kohrt BA. A Cultural Adaptation of Dialectical Behavior Therapy in Nepal. COGNITIVE AND BEHAVIORAL PRACTICE 2017; 24:428-444. [PMID: 29056846 PMCID: PMC5645023 DOI: 10.1016/j.cbpra.2016.12.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.
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Affiliation(s)
- Megan K. Ramaiya
- Duke Global Health Institute, 310 Trent Drive, Durham, NC
- Department of Psychology, University of Washington, Box 351525, Seattle, WA
| | - Devika Fiorillo
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Dr. NE, Atlanta, GA
| | - Upasana Regmi
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Clive J. Robins
- Department of Psychology & Neuroscience, Duke University, Box 90086, 417 Chapel Drive, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University, Box 90519 Durham, NC
| | - Brandon A. Kohrt
- Duke Global Health Institute, 310 Trent Drive, Durham, NC
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Department of Psychiatry and Behavioral Sciences, Duke University, Box 90519 Durham, NC
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Chase L, Sapkota RP. "In our community, a friend is a psychologist": An ethnographic study of informal care in two Bhutanese refugee communities. Transcult Psychiatry 2017; 54:400-422. [PMID: 28475482 DOI: 10.1177/1363461517703023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews ( n = 40, camp community; n = 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the "heart-mind" and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts.
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Gautam R, Mawn BE, Beehler S. Bhutanese Older Adult Refugees Recently Resettled in the United States: A Better Life With Little Sorrows. J Transcult Nurs 2017; 29:165-171. [PMID: 28826370 DOI: 10.1177/1043659617696975] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This study explores the experiences and adjustment process among older Bhutanese refugees resettled in the United States and identifies their unmet health and social service needs. DESIGN This phenomenological study design included the conduction of nine in-depth semistructured interviews in the respondents' native language. The researchers adhered to the steps outlined by Moustakas for data analysis. RESULTS The five identified themes included the following: a better life but with little sorrows, cultural tensions related to adaptation, language as a barrier to success in the United States, isolation and loneliness, and worries about citizenship and its impact on the future. Discussion/Implications for Practice: Psychological adjustment to life in the United States can have profound impact on the health of Bhutanese older adults. Nurses and health care providers should integrate culturally congruent health care, raise awareness of the unique needs, and advocate for policy changes that will benefit this group of older adult refugees whose lives have frequently been upended.
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Affiliation(s)
- Ramraj Gautam
- 1 University of Massachusetts Lowell, Lowell, MA, USA
| | | | - Sarah Beehler
- 2 Department of Biobehaviroal Health & Population Sciences, University of Minnesota Medical School, Duluth Campus, MN, USA
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Vargas-Espíndola A, Villamizar-Guerrero JC, Puerto-López JS, Rojas-Villamizar MR, Ramírez-Montes OS, Urrego-Mendoza ZC. Conducta suicida en pueblos indígenas: una revisión del estado del arte. REVISTA DE LA FACULTAD DE MEDICINA 2017. [DOI: 10.15446/revfacmed.v65n1.54928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Se realizó una revisión documental en bases de datos sobre conducta suicida en pueblos indígenas, tipo estado del arte, que la identificara como un problema de salud pública.Objetivo. Sistematizar el estado del conocimiento que se construye sobre la conducta suicida en pueblos indígenas, a partir de artículos e informes de investigación publicados hasta 2014.Materiales y métodos. Revisión documental de 149 documentos publicados sobre conducta suicida en pueblos indígenas, que fueron analizados según aspectos cronológicos, topográficos, de enfoque y contenido.Resultados. La literatura revisada indica que la tasa de suicidios en los pueblos originarios es mayor que el de la población general en el mundo (sobre todo en jóvenes). El enfoque prevalente de los estudios revisados es cualitativo o epidemiológico desde factores de riesgo. Por lo general, la conducta suicida en pueblos indígenas se observa epidemiológicamente desde un enfoque clásico que ignora su cosmovisión. Por lo tanto, este fenómeno se debe comprender más como un hecho social que individual, en el cual existe un desequilibrio entre procesos destructivos y protectores de salud y vida.Conclusiones. La conducta suicida en pueblos indígenas es un problema de salud pública, cuyo estudio integral se debe fomentar desde un enfoque intercultural para facilitar el trazado de estrategias de intervención, apropiadas a las necesidades de los pueblos afectados.
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Kohrt BA, Worthman CM, Adhikari RP, Luitel NP, Arevalo JMG, Ma J, McCreath H, Seeman TE, Crimmins EM, Cole SW. Psychological resilience and the gene regulatory impact of posttraumatic stress in Nepali child soldiers. Proc Natl Acad Sci U S A 2016; 113:8156-61. [PMID: 27402736 PMCID: PMC4961140 DOI: 10.1073/pnas.1601301113] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Adverse social conditions in early life have been linked to increased expression of proinflammatory genes and reduced expression of antiviral genes in circulating immune cells-the conserved transcriptional response to adversity (CTRA). However, it remains unclear whether such effects are specific to the Western, educated, industrialized, rich, and democratic (WEIRD) cultural environments in which previous research has been conducted. To assess the roles of early adversity and individual psychological resilience in immune system gene regulation within a non-WEIRD population, we evaluated CTRA gene-expression profiles in 254 former child soldiers and matched noncombatant civilians 5 y after the People's War in Nepal. CTRA gene expression was up-regulated in former child soldiers. These effects were linked to the degree of experienced trauma and associated distress-that is, posttraumatic stress disorder (PTSD) severity-more than to child soldier status per se. Self-perceived psychological resilience was associated with marked buffering of CTRA activation such that PTSD-affected former child soldiers with high levels of personal resilience showed molecular profiles comparable to those of PTSD-free civilians. These results suggest that CTRA responses to early life adversity are not restricted to WEIRD cultural contexts and they underscore the key role of resilience in determining the molecular impact of adverse environments.
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Affiliation(s)
- Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27708; Duke Global Health Institute, Duke University, Durham, NC 27710; Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal;
| | | | - Ramesh P Adhikari
- Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal
| | - Jesusa M G Arevalo
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Jeffrey Ma
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Heather McCreath
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Teresa E Seeman
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Epidemiology, University of California, Los Angeles School of Public Health, Los Angeles, CA 90095
| | - Eileen M Crimmins
- Davis School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - Steven W Cole
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
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Hagaman AK, Maharjan U, Kohrt BA. Suicide surveillance and health systems in Nepal: a qualitative and social network analysis. Int J Ment Health Syst 2016; 10:46. [PMID: 27274355 PMCID: PMC4895957 DOI: 10.1186/s13033-016-0073-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 05/10/2016] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Ashley K. Hagaman
- />School of Human Evolution and Social Change, Arizona State University, Tempe, USA
| | - Uden Maharjan
- />Health Research and Social Development Forum, Kathmandu, Nepal
| | - Brandon A. Kohrt
- />Duke Global Health Institute and Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC USA
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Betancourt TS, Frounfelker R, Mishra T, Hussein A, Falzarano R. Addressing health disparities in the mental health of refugee children and adolescents through community-based participatory research: a study in 2 communities. Am J Public Health 2015; 105 Suppl 3:S475-82. [PMID: 25905818 DOI: 10.2105/ajph.2014.302504] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to understand the problems, strengths, and help-seeking behaviors of Somali Bantu and Bhutanese refugees and determine local expressions of mental health problems among youths in both communities. METHODS We used qualitative research methods to develop community needs assessments and identify local terms for child mental health problems among Somali Bantu and Bhutanese refugees in Greater Boston and Springfield, Massachusetts, between 2011 and 2014. A total of 56 Somali Bantu and 93 Bhutanese refugees participated in free list and key informant interviews. RESULTS Financial and language barriers impeded the abilities of families to assist youths who were struggling academically and socially. Participants identified resources both within and outside the refugee community to help with these problems. Both communities identified areas of distress corresponding to Western concepts of conduct disorders, depression, and anxiety. CONCLUSIONS There are numerous challenges faced by Somali Bantu and Bhutanese youths, as well as strengths and resources that promote resilience. Future steps include using culturally informed methods for identifying those in need of services and developing community-based prevention programs.
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Affiliation(s)
- Theresa S Betancourt
- Theresa S. Betancourt and Tej Mishra are with the Department of Global Health and Population, Research Program on Children and Global Adversity, Harvard T. H. Chan School of Public Health, Boston, MA. Rochelle Frounfelker is with the Department of Social and Behavioral Sciences, Research Program on Children and Global Adversity, Harvard T. H. Chan School of Public Health. Aweis Hussein and Rita Falzarano are with Shanbaro Association, Chelsea Collaborative, Chelsea, MA
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Kohrt BA, Jordans MJD, Rai S, Shrestha P, Luitel NP, Ramaiya MK, Singla DR, Patel V. Therapist competence in global mental health: Development of the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale. Behav Res Ther 2015; 69:11-21. [PMID: 25847276 DOI: 10.1016/j.brat.2015.03.009] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
Lack of reliable and valid measures of therapist competence is a barrier to dissemination and implementation of psychological treatments in global mental health. We developed the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale for training and supervision across settings varied by culture and access to mental health resources. We employed a four-step process in Nepal: (1) Item generation: We extracted 1081 items (grouped into 104 domains) from 56 existing tools; role-plays with Nepali therapists generated 11 additional domains. (2) Item relevance: From the 115 domains, Nepali therapists selected 49 domains of therapeutic importance and high comprehensibility. (3) Item utility: We piloted the ENACT scale through rating role-play videotapes, patient session transcripts, and live observations of primary care workers in trainings for psychological treatments and the Mental Health Gap Action Programme (mhGAP). (4) Inter-rater reliability was acceptable for experts (intraclass correlation coefficient, ICC(2,7) = 0.88 (95% confidence interval (CI) 0.81-0.93), N = 7) and non-specialists (ICC(1,3) = 0.67 (95% CI 0.60-0.73), N = 34). In sum, the ENACT scale is an 18-item assessment for common factors in psychological treatments, including task-sharing initiatives with non-specialists across cultural settings. Further research is needed to evaluate applications for therapy quality and association with patient outcomes.
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Affiliation(s)
- Brandon A Kohrt
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal; Department of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine, Washington, DC, United States; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, United States; Duke Global Health Institute, Duke University, Durham, United States.
| | - Mark J D Jordans
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom; Research and Development, HealthNet TPO, Amsterdam, The Netherlands
| | - Sauharda Rai
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal; Duke Global Health Institute, Duke University, Durham, United States
| | - Pragya Shrestha
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Megan K Ramaiya
- Duke Global Health Institute, Duke University, Durham, United States
| | - Daisy R Singla
- Department of Psychology, McGill University, Montreal Quebec, Canada
| | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom; Public Health Foundation of India, New Delhi, India; Sangath Center, Alto Porvorim Goa, India
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Kriegler S, Bester SE. A critical engagement with the DSM-5 and psychiatric diagnosis. JOURNAL OF PSYCHOLOGY IN AFRICA 2014. [DOI: 10.1080/14330237.2014.980629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Susan Kriegler
- Department of Educational Psychology, University of Pretoria, South Africa
| | - Suzanne E Bester
- Department of Educational Psychology, University of Pretoria, South Africa
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Niraula K, Kohrt BA, Flora MS, Thapa N, Mumu SJ, Pathak R, Stray-Pedersen B, Ghimire P, Regmi B, MacFarlane EK, Shrestha R. Prevalence of depression and associated risk factors among persons with type-2 diabetes mellitus without a prior psychiatric history: a cross-sectional study in clinical settings in urban Nepal. BMC Psychiatry 2013; 13:309. [PMID: 24238561 PMCID: PMC3833646 DOI: 10.1186/1471-244x-13-309] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 11/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes is a growing health problem in South Asia. Despite an increasing number of studies exploring causal pathways between diabetes and depression in high-income countries (HIC), the pathway between the two disorders has received limited attention in low and middle-income countries (LMIC). The aim of this study is to investigate the potential pathway of diabetes contributing to depression, to assess the prevalence of depression, and to evaluate the association of depression severity with diabetes severity. This study uses a clinical sample of persons living with diabetes sequelae without a prior psychiatric history in urban Nepal. METHODS A cross-sectional study was conducted among 385 persons living with type-2 diabetes attending tertiary centers in Kathmandu, Nepal. Patients with at least three months of diagnosed diabetes and no prior depression diagnosis or family history of depression were recruited randomly using serial selection from outpatient medicine and endocrine departments. Blood pressure, anthropometrics (height, weight, waist and hip circumference) and glycated hemoglobin (HbA1c) were measured at the time of interview. Depression was measured using the validated Nepali version of the Beck Depression Inventory (BDI-Ia). RESULTS The proportion of respondents with depression was 40.3%. Using multivariable analyses, a 1-unit (%) increase in HbA1c was associated with a 2-point increase in BDI score. Erectile dysfunction was associated with a 5-point increase in BDI-Ia. A 10 mmHg increase in blood pressure (both systolic and diastolic) was associated with a 1.4-point increase in BDI-Ia. Other associated variables included waist-hip-ratio (9-point BDI-Ia increase), at least one diabetic complication (1-point BDI-Ia increase), treatment non-adherence (1-point BDI-Ia increase), insulin use (2-point BDI-Ia increase), living in a nuclear family (2-point BDI-Ia increase), and lack of family history of diabetes (1-point BDI-Ia increase). Higher monthly income was associated with increased depression severity (3-point BDI-Ia increase per 100,000 rupees, equivalent US$1000). CONCLUSIONS Depression is associated with indicators of more severe diabetes disease status in Nepal. The association of depression with diabetes severity and sequelae provide initial support for a causal pathway from diabetes to depression. Integration of mental health services in primary care will be important to combat development of depression among persons living with diabetes.
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Affiliation(s)
- Kiran Niraula
- Department of Epidemiology and Biostatistics, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh.
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Meerjady Sabrina Flora
- Department of Epidemiology, National Institute of Preventive and Social Medicine, Dhaka, Bangladesh
| | - Narbada Thapa
- Department of Community Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Shirin Jahan Mumu
- Department of Epidemiology, Bangladesh University of Health Sciences, Dhaka, Bangladesh
| | - Rahul Pathak
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Babill Stray-Pedersen
- Institute of Clinical Medicine, University of Oslo - Division of Women and Children, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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Chase LE, Welton‐Mitchell C, Bhattarai S. “Solving Tension”: coping among Bhutanese refugees in Nepal. INTERNATIONAL JOURNAL OF MIGRATION HEALTH AND SOCIAL CARE 2013. [DOI: 10.1108/ijmhsc-05-2013-0001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hagaman AK, Wagenaar BH, McLean KE, Kaiser BN, Winskell K, Kohrt BA. Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention. Soc Sci Med 2013; 83:61-9. [PMID: 23465205 DOI: 10.1016/j.socscimed.2013.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 01/18/2013] [Accepted: 01/24/2013] [Indexed: 11/15/2022]
Abstract
Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs.
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Affiliation(s)
- Ashley K Hagaman
- Department of Global Health, School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85251, USA.
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