Political violence and mental health in Nepal: Prospective study

Department of Psychiatry and Behavioral Sciences, The George Washington University, 2150 Pennsylvania Avenue, 8th Floor, Washington, DC 20037, USA. .
The British journal of psychiatry: the journal of mental science (Impact Factor: 7.99). 08/2012; 201(4):268-75. DOI: 10.1192/bjp.bp.111.096222
Source: PubMed


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

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Available from: Brandon A Kohrt, Sep 13, 2015
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    • "We developed this tool within a task-sharing initiative in a low-income, non-Western cultural setting. Nepal, a post-conflict country in South Asia with high prevalence of depression (Kohrt et al., 2012a) and suicide (Jordans et al., 2014), is participating in the Programme to Improve Mental Health Care (PRIME), an initiative in LMICs to develop mental health care in primary and community health settings (Jordans, Luitel, Tomlinson, & Komproe, 2013; Lund et al., 2012). In Nepal's Chitwan District, primary care and community health workers are being trained with a locally developed Mental Health Care Package (Jordans, Luitel, Pokharel, & Patel, in press), which includes the mental health Gap Action Programme—Intervention Guide (mhGAP-IG) (WHO, 2010), psychosocial skills modules, and brief modified versions of behavior activation (the Healthy Activity Program, HAP) and motivational interviewing (Counseling for "
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    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. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
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    • "This includes an environment where people are at increased risk of depression, anxiety and post-traumatic stress disorder [4]. Poverty, female gender discrimination and caste inequality are also causal factors that contribute to mental health problems such as depression [5]. Less than 1% of the national health budget is presently allocated to mental health [6]. "
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    • "A higher rate of trauma experience has been identified as a risk factor for anxiety disorders in most of the limited number of studies in conflict and post-conflict settings [6,19]. A study from Nepal [53] indicated a dose–response effect of number of types of conflict events on anxiety. However, another study among the displaced population in Nepal [54] did not show any significant association between trauma exposure and anxiety symptomatology. "
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