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To date, there have been no cohort studies of sexual harassment incidence and its relation to mental health within humanitarian field-workers. Research among numerous occupations suggests an association between workplace sexual harassment and several health complaints. This study examined the incidence and severity of sexual harassment and its association with changes in mental health in a cohort of international humanitarian aid field-workers (iHAWs). Four hundred and seventy-eight iHAWs filled in questionnaires about sexual harassment, depression, anxiety, and Post-Traumatic Stress Disorder (PTSD) as part of a larger study on health and well-being. Six percent of male and 18% of female iHAWs reported experiencing sexual harassment during their latest field assignment, with most reporting low levels of nonphysical forms of sexual harassment. Sexual harassment was predictive of negative changes in both depression and anxiety symptom severity between before and after an assignment for females; for males, it predicted negative changes in PTSD symptom severity. Sexual harassment did not predict utilization of mental healthcare services within 2 months after the end of assignment. The current findings are the first figures derived from a representative sample of iHAWs on the incidence of sexual harassment during a field assignment and show sexual harassment to be a relatively common and present issue. The findings are mostly in line with the extant literature and underscore the importance of attending to the issue of sexual harassment in the humanitarian sector.

Background: Posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) are known psychological outcomes that can co-occur in the aftermath of a traumatic event. However, it is less clear how these outcomes interact – particularly for female survivors of conflict-related sexual violence (CRSV) – and to what extent intermediary factors play a role in this relationship. Methods: In a sample of 192 war survivors from Bosnia & Herzegovina (n = 104 experienced CRSV, n = 88 did not), a structural equation model (LISREL 8.8) tested CRSV as a traumatic event, 'positive reinterpretation' (as a strategy of approach coping) and 'behavioural disengagement' (as a strategy of avoidance coping), and PTSD and PTG as psychosocial outcomes. A difference in the mechanisms by which PTG and PTSD interact in the two subgroups was hypothesised, given the differences in the nature of the trauma they experienced. Results: Through multiple indirect relationships, results showed that CRSV survivors respond to their trauma with both PTSD and PTG, suggesting a dual PTSDPTG mechanism. As for coping strategies, positive reinterpretation predicted greater PTG, and behavioural disengagement predicted greater PTSD. In the sample of nonsexual violence survivors, positive reinterpretation also remained a significant predictor of PTG. Conclusions: Positive reinterpretation as a coping strategy appears to be a stable characteristic that independently predicts PTG, irrespective of trauma type. Mental health professionals should take into account this mechanism when addressing the needs of CRSV survivors, but also war survivors more generally. Reframing traumatic events and post-trauma sequalae during treatment could lead to PTG and enhance recovery.

This exploratory study empirically shows how community social capital is related to post-disaster depression, whereas most disaster mental health research has focused on posttraumatic stress disorder. We tested the validity of earlier found multilevel social and individual mechanisms of posttraumatic stress for symptoms of post-disaster depression. We used data (n = 231) from a community study after a flood in Morpeth (2008), a rural town in northern England. At the salutary community level, our multilevel analyses showed that, in communities with high social capital, individuals employ less individual social support and coping effort, which protects individuals from developing symptoms of depression. Yet, on the ‘dark’ individual level of our model, we found that perceiving the disaster as less traumatic after a year was related to more feelings of depression in contrast to previous findings for posttraumatic stress. Our explanation of this finding is that, when the appraisal of the disaster as threatening fades into the background, individuals may perceive the full scope of the disaster aftermath and start to feel depressed. We also found that more social support is related to more depression. Although depressed people may attract or receive more social support, this social support can paradoxically become disabling by reinforcing a sense of dependence, thereby undermining self-esteem and leading to feelings of helplessness. Our results imply that to curb post-disaster depression, boosting community level social capital may be an important starting point for building resilience. At the same time, interventionists need to identify risk groups for whom the stressful experience becomes less intrusive and who experience the burden of dependency on an unequal relationship with ones’ social inner circle.

Background Integration of mental health services into primary health care systems has been advocated as a strategy to minimize the tremendous mental health treatment gap, particularly in low- and middle-income countries. Barriers to integration of mental health into primary health care have been widely documented; however, very little is known about the perception of service users and their caregivers on primary care-based mental health services. This study assessed service users’ and caregivers’ perceptions of mental health services provided by trained primary health care workers in Nepal. Methods A qualitative study was conducted among people with depression, psychosis, alcohol use disorder and epilepsy, and their caregivers in Chitwan, a district in southern Nepal. Semi-structured interviews were conducted with 43 service users and 38 caregivers to assess their perceptions about the accessibility of the services, types of services they received, skills and competencies of health care providers, satisfaction and barriers to receiving services. Results Overall, both service users and caregivers were satisfied with the mental health services provided by primary health care providers. They also perceived health workers to be competent and skillful because the services they received were effective in reducing their mental health problems. Both psychological and pharmacological services were made available free of cost, however, they considered psychological services more effective than pharmacological treatment. Major challenges and difficulties accessing services were associated with frequent transfer of trained health workers, non-availability of the same health care provider at follow-ups, frequent stock-out of medicines or non-availability of required medicines, lack of a confidential space for consultation in health facilities, and stigmatizing and negative behavior of some health workers. Conclusion The results demonstrated that both service users and caregivers perceived primary care-based mental health services to be accessible, acceptable and effective. The key recommendations emerging from this study for improving mental health services in primary care include the provision of a separate cadre of psychosocial workers to provide psychological interventions, developing quick and efficient mechanisms for the procurement and supply of psychotropic medicines, establishing a confidential place within health facilities for consultation, and further training of health workers to reduce stigma.

Background The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal. Aims To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP. Method A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers. Results The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors. Conclusions Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.

Background Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness. Methods A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline). Results From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support. Conclusions These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.

Background The barriers and facilitating factors for integrating mental health into primary health care have been well documented in the literature, but little is known about the perspectives of primary health care workers (who provide integrated mental health care) on barriers and facilitating factors of the health system for scaling up mental health interventions in low and middle income countries. This study aimed to explore these perspectives of primary health care workers within the health system, and identify possible strategies to optimize the integration of mental health in primary health care. Methods The study was conducted in the Chitwan district of Nepal with 55 purposively selected primary health care workers representing prescribers (N = 35), non-prescribers (N = 12) and Female Community Health Volunteers (N = 8). Using a semi-structured interview guide, experienced qualitative researchers collected data between September 2016 and May 2017. The interviews were audio-taped, transcribed and then translated into English. The transcripts were coded using Nvivo 10 software and themes were generated for the thematic analysis. Results According to the health workers, the facilitating factors for scaling up mental health services in primary health care setting in Nepal included; (1) availability of guidelines, protocols and awareness raising materials, (2) provision of supervision, (3) referral systems being in place, (4) patient record keeping, (5) community sensitizations and home visits, and (6) provision of psychosocial counseling. The barriers identified included; (1) shortage of psychotropic medicines, (2) lack of private space for counseling, (3) workload and health workers’ grievances regarding incentives, and (4) perceived stigma causing dropouts. Conclusions The findings suggest that implementation of mental health services through primary health care workers in resource-poor setting is possible when health system level barriers are addressed and facilitating factors are strengthened. In order to address these barriers the health workers suggested a few strategies which included; ensuring dedicated staff available at health facility, allocating dedicated and confidential space for counseling, improving on incentives and motivational benefits to existing health staff, organizing policy level advocacy for mental health, improving medicine supply chain management and strengthening systems for supervision, referral and mental health information management.

Background In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing. Methods and findings A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment. Conclusions These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression)., Using data from Chitwan district in Nepal, Mark Jordans and colleagues reveal the benefits and impact of community-based mental health care in rural settings, where such care is often absent., Author summary Why was this study done? Following World Health Organization guidance on the integration of mental health into primary healthcare, there is a need for more evidence for the feasibility of the Mental Health Gap Action Programme (mhGAP) for scale-up of mental healthcare in low- and middle-income settings. This study evaluated a comprehensive mental healthcare plan at the district level in rural Nepal, a setting exemplifying scarce access to mental health services. What did the researchers do and find? After implementing a district mental health plan, the percentage of persons in the community receiving treatment increased from 0% to 12% for depression, 0% to 8% for alcohol use disorder, 3% to 53% for psychosis, and 1% to 13% for epilepsy. Six months after training, health workers detected 1 out of 4 patients with depression (1 out of 5 patients 2 years after training) and 3 out of 5 patients with alcohol use disorder (1 out of 8 patients 2 years after training) among patients presenting to primary care facilities. Of the patients detected with depression and with alcohol use disorder 95% received minimally adequate care (at 2 years after training this was 2 out of 3 for depression, and 3 out of 4 for alcohol use disorder). Patients treated for depression, alcohol use disorder, or psychosis showed small to moderate improvements in both symptoms and daily functioning at 12 months after starting treatment. What do these findings mean? Having health workers who are not specialists deliver community- and primary-healthcare-based mental health services is a promising strategy to increase the number of people with mental health problems benefiting from such care. Future implementation should increase supervision and quality assurance among the trained health workers, as well as ensuring that community-level interventions go hand-in-hand with those in health facilities.

BackgroundAccurate detection of persons in need of mental healthcare is crucial to reduce the treatment gap between psychiatric burden and service use in low- and middle-income (LAMI) countries.AimsTo evaluate the accuracy of a community-based proactive case-finding strategy (Community Informant Detection Tool, CIDT), involving pictorial vignettes, designed to initiate pathways for mental health treatment in primary care settings.MethodCommunity informants using the CIDT identified screen positive (n = 110) and negative persons (n = 85). Participants were then administered the Composite International Diagnostic Interview (CIDI).ResultsThe CIDT has a positive predictive value of 0.64 (0.68 for adults only) and a negative predictive value of 0.93 (0.91 for adults only).ConclusionsThe CIDT has promising detection properties for psychiatric caseness. Further research should investigate its potential to increase demand for, and access to, mental health services.

Background Psychotropic drugs play an important role in the treatment of mental, neurological and substance use disorders. Despite the advancement of the use of psycho-pharmaceuticals in the developed countries, the psychotropic drug production and supply chain management in low- and middle- income countries are still poorly developed. This study aims to explore the perceptions of stakeholders involved in all stages of the psychotropic drug supply chain about the need, quality, availability and effectiveness of psychotropic drugs, as well as barriers to their supply chain management. The study was conducted among 65 respondents from the Kathmandu, Chitwan and Pyuthan districts, grouped into four categories: producers, promoters and distributors (N = 22), policy makers and government actors (N = 8), service providers (N = 21) and service users/family members (N = 14). Results The respondents reported that psychotropic drugs, despite having side effects, are 1) needed, 2) available in major regional centers and 3) are effective for treating mental health problems. The stigma associated with mental illness, however, forces patients and family members to hide their use of psychotropic drugs. The study found that the process of psychotropic drug supply chain management is similar to other general drugs, with the exceptions of strict pre-approval process, quantity restriction (for production and import), and mandatory record keeping. Despite these regulatory provisions, respondents believed that the misuse of psychotropic drugs is widespread and companies are providing incentives to prescribers and retailers to retain their brand in the market. Conclusions The production and supply chain management of psychotropic drugs is influenced by the vested interests of pharmaceutical companies, prescribers and pharmacists. In the context of the government of Nepal’s policy of integrating mental health into primary health care and increased consumption of psychotropic drugs in Nepal, there is a need for massive education and awareness as well as strict monitoring and supervision to avoid the misuse of psychotropic drugs. Electronic supplementary material The online version of this article (10.1186/s12992-018-0322-4) contains supplementary material, which is available to authorized users.

IntroductionVery little is known on the impact of recurrent disasters on mental health.AimThe present study examines the immediate impact of a recurrent flood on mental health and functioning among an affected population in the rural district of Bahraich, Uttar Pradesh, India, compared with a population in the same region that is not affected by floods.MethodsThe study compared 318 affected respondents with 308 individuals who were not affected by floods. Symptoms of anxiety and depression were assessed by the Hopkins Symptom Checklist-25 (HSCL-25). Psychological and physical functioning was assessed by using the Short Form-12 (SF-12).ResultsThe affected group showed large to very large differences with the comparison group on symptoms of anxiety (D = .92) and depression (D = 1.22). The affected group scored significantly lower on psychological and physical functioning than the comparison group (respectively D = .33 and D = .80). However, hierarchical linear regressions showed no significant relationship between mental health and the domains of functioning in the affected group, whereas mental health and the domains of functioning were significantly related in the comparison group.ConclusionThis study found a large negative impact of the recurrent floods on mental health outcomes and psychological and physical functioning. However, in a context with recurrent floods, disaster mental health status is not a relevant predictor of functioning. The findings suggest that the observed mental health status and impaired functioning in this context are also outcomes of another mechanism: Both outcomes are likely to be related to the erosion of the social and environmental and material context. As such, the findings refer to a need to implement psychosocial context-oriented interventions to address the erosion of the context rather than specific mental health interventions.WindTR, JoshiPC, KleberRJ, KomproeIH. The impact of recurrent disasters on mental health: a study on seasonal floods in northern India. Prehosp Disaster Med. 2013;28(3):1-7.

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n = 1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client’s problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

Conduct problems and emotional distress have been identified as key problems among children and adolescents in post-war Burundi. This pilot study aims to evaluate the impact of a brief parenting psychoeducation intervention on children’s mental health. This study employs a controlled pre and post evaluation design. The two-session psychoeducation intervention was offered to groups of parents of children (mean age 12.3 years, 60.8 % female) who had been screened for elevated psychosocial distress. Children in the intervention group (n = 58) were compared to a waitlist control group (n = 62). Outcome indicators included child-reported levels of aggression (using the Aggression Questionnaire), depression symptoms (using the Depression Self Rating Scale) and perceived family social support. The intervention had a beneficial effect on reducing conduct problems compared to the control condition (Cohen d = 0.60), especially among boys, while not showing impact on depression symptoms or family social support. Parents evaluated the intervention positively, with increased awareness of positive parenting strategies and appropriate disciplinary techniques reported as the most common learning points. A brief parenting psychoeducation intervention conducted by lay community counselors is a promising public health strategy in dealing with widespread conduct problems in boys living in violence-affected settings and not so for social and emotional indicators and for girls. An efficacy study is warranted to confirm these preliminary findings.

Background: Research on information systems for mental health in low and middle income countries (LMICs) is scarce. As a result, there is a lack of reliable information on mental health service needs, treatment coverage and the quality of services provided.Methods: With the aim of informing the development and implementation of a mental health information sub-system that includes reliable and measurable indicators on mental health within the Health Management Information Systems (HMIS), a cross-country situation analysis of HMIS was conducted in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda), participating in the ‘Emerging mental health systems in low and middle income countries’ (Emerald) research programme. A situation analysis tool was developed to obtain and chart information from documents in the public domain. In circumstances when information was inadequate, key government officials were contacted to verify the data collected. In this paper we compare the baseline policy context, human resources situation as well as the processes and mechanisms of collecting, verifying, reporting and disseminating mental health related HMIS data.Results: The findings suggest that countries face substantial policy, human resource and health governance challenges for mental health HMIS, many of which are common across sites. In particular, the specific policies and plans for the governance and implementation of mental health data collection, reporting and dissemination are absent. Across sites there is inadequate infrastructure, few HMIS experts, and inadequate technical support and supervision to junior staff, particularly in the area of mental health. Nonetheless there are also strengths in existing HMIS where a few mental health morbidity, mortality, and system level indicators are collected and reported.Conclusions: Our study indicates the need for greater technical and resources input to strengthen routine HMIS and develop standardized HMIS indicators for mental health, focusing in particular on indicators of coverage and quality to facilitate the implementation of the WHO mental health action plan 2013–2020.

The aim of this epidemiological study was to identify prevalence rates of mental health problems, factors associated with poor mental health and protective and risk factors in a post-conflict situation in Nepal. This cross-sectional study was conducted among 720 adults in 2008. A three-stage sampling procedure was used following a proportionate stratified random sampling strategy. The outcome measures used in the study were locally validated with Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Post-Traumatic Stress Disorder (PTSD)—Civilian Version (PCL-C) and locally constructed function impairment scale, resources and coping. Of the sample, 27.5 % met threshold for depression, 22.9 % for anxiety, and 9.6 % for PTSD. Prevalence rates were higher among women (depression, OR 2.14 [1.52–3.47]; anxiety, OR 2.30 [1.45–3.17] and PTSD, OR 3.32 [1.87–5.89]) and older age categories (depression, OR 1.02 [1.01–1.04]; anxiety, OR 1.04 [1.03–1.05] and PTSD, OR 1.02 [1.0–1.03]). Respondents who perceived more negative impact of the conflict (e.g., hampered the business/industry; hindered in getting medical treatment, etc.) in their communities were more at risk for depression (OR 1.1 [1.06–1.14]), anxiety (OR 1.05 [1.01–1.09]) and PTSD (OR 1.09 [1.04–1.14]). Other risk factors identified in the study were ethnicity, district of residence and poverty (lack of clothing, medicine and information via radio at home). Overall, the prevalence rates of depression and anxiety in the sample are comparable to, or lower than, other studies conducted with populations affected by conflict and with refugees. However, the findings underscore the need to address the current lack of mental health care resources in post-conflict rural Nepal, especially for marginalized populations.

This study aimed to develop a research strategy to make informed decisions for intervention selection, especially for low- and middle-income countries, as a response to the urgent need to scale-up mental health care for children globally. With this study we address the critical lack of translation of research findings into policy and practice. The research strategy was piloted for development of a family-based intervention in violence-affected areas in Burundi. The research comprised four phases; (a) a qualitative phase to assess needs and determine tentative intervention objectives; (b) a global expert panel to identify and prioritize intervention modalities for low-resource settings; (c) systematic literature review and distillation of practice elements from evidence-based treatments; and (d) stakeholder meetings to explore social-cultural feasibility and acceptability of the developed intervention. The study was conducted between January and November 2010. The research strategy resulted in the development of a stepped family-based care intervention, which combines community mobilization, parent-management training and cognitive behavior therapy elements. This pilot-tested research strategy, encompassing global and local knowledge on needs, feasibility and effectiveness, has the potential to be useful for developing mental health and psychosocial interventions in other settings.

Objective: Practitioners in political violence-affected settings would benefit from rating scales that assess child function impairment in a reliable and valid manner when designing and evaluating interventions. We developed a procedure to construct child function impairment rating scales using resources available in low- and middle-income countries.Design: We applied a mixed methods approach. First, rapid ethnographic methods (brief participant observation, collection of diaries and a focus group with children) were used to select daily activities that best represented children's functioning. Second, rating scales based on these activities were examined for their psychometric properties. Construct validity was assessed through a confirmatory factor analysis procedure.Setting: Central Sulawesi, Indonesia.Participants: Qualitative data were collected for 53 children and psychometric testing was done with 403 children [average age: 9.9 (SD = 1.21), 49% girls] and 385 parents.Results: Using locally available resources, we developed separate child-rated and parent-rated scales, both containing 11 items. The child-rated scale evidenced good internal, test-retest and inter-rater reliability and acceptable convergent and discriminant validity. Construct validity was confirmed by fit of the theorized factor structure—a social-ecological clustering of daily activities.Conclusions: The procedure resulted in a reliable and valid rating scale to assess child function impairment in the context of political violence. Practitioners can apply this procedure to develop new locally adequate rating scales to strengthen epidemiological surveys, baseline assessments, monitoring and evaluation and eventually, interventions. Further research should address the importance of gender differences and criterion-related validity.

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Background: In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low‐ and middle‐income countries. This study evaluated a school‐based psychosocial intervention in conflict‐affected, rural Nepal. Methods: A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11–14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. Results: Comparisons of crude change scores showed significant between‐group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (−2.19; 95% CI, −3.82 to −.56), and aggression (−4.42; 95% CI, −6.16 to −2.67). An age effect for treatment was found for hope (.90; 95% CI, −1.54 to −.26). Conclusions: A school‐based psychosocial intervention demonstrated moderate short‐term beneficial effects for improving social‐behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

The present study explores whether severe life-events are associated with adjustment disorders (AD) by reanalyzing the data of a multisite epidemiological survey (de Jong et al. in Lancet 361:2128–2130, 2003). AD were diagnosed according to the new stress-response-model of AD (Maercker et al. in Psychopathology 40(3):135–146, 2007). Data from 3048 persons from four different refugee settings in Ethiopia, Algeria, Gaza, and Cambodia were reanalyzed. Life events were assessed by an adapted version of the Life Events and Social History Interview (Mollica et al. in Am J Psychiatry 144:1567–1572, 1987). The current study focuses on non-directly life threatening events related to AD (e.g. loss of property) in contrast to life-threatening events related to Posttraumatic Stress Disorders (PTSD). AD Symptom measures were obtained from available psychopathology assessments: composite international diagnostic interview (WHO in CIDI, Geneva, 1997) and structured interview for disorders of extreme stress (Pelcovitz et al. J Trauma Stress 10:3–16, 1997). The majority of the subjects had experienced one or more AD-related life event. Most common AD-related life events varied across the four sites with bad shelter conditions most prevalent in Ethiopia (100%) and Gaza (32%), forced social isolation in Algeria (61%), and lack of food in Cambodia (41%). Prevalences of AD diagnoses ranged from 6% (Ethiopia) to 40% (Algeria). The highest rates of comorbidity were between AD and PTSD, followed by anxiety disorders. The present study shows that the new concept of AD can be of use for psychiatric epidemiology, e.g., in migration contexts. The high-comorbidity rates could indicate that AD and PTSD are parts of a stress response spectrum.

Objective: The authors examined moderators and mediators of a school-based psychosocial intervention for children affected by political violence, according to an ecological resilience theoretical framework. Method: The authors examined data from a cluster randomized trial, involving children aged 8-13 in Central Sulawesi, Indonesia (treatment condition n = 182, waitlist control condition n = 221). Mediators (hope, coping, peer/emotional/play social support) and moderators (gender, age, family connectedness, household size, other forms of social support, exposure to political violence, and displacement) of treatment outcome on posttraumatic stress symptoms and function impairment were examined in parallel process latent growth curve models. Results: Compared with the waitlist group, those receiving treatment showed maintained hope, increased positive coping, maintained peer social support, and increased play social support. Of these putative mediators, only play social support was found to mediate treatment effects, such that increases in play social support were associated with smaller reductions in posttraumatic stress disorder (PTSD) symptoms. Furthermore, the authors identified a number of moderators: Girls showed larger treatment benefits on PTSD symptoms; girls, children in smaller households, and children receiving social support from adults outside the household showed larger treatment benefits on function impairment. Conclusions: Findings provide limited evidence for an ecological resilience theoretical framework. On the basis of these findings, the authors recommend a stronger separation between universal prevention (e.g., resilience promotion through play) and selective/indicated prevention (e.g., interventions aimed at decreasing posttraumatic stress symptoms). Play-based interventions should be careful to exclude children with psychological distress. In addition, treatment effects may be augmented by selecting girls and socially vulnerable children.

Background: There is a growing body of literature on interventions addressing psychosocial wellbeing and mental health of children affected by violence in low- and middle-income countries. Methods: This systematic review of PubMed, PsychINFO, and PILOTS identified 500 publications (1991‐2008) on interventions. Results: Sixty-six publications (12 treatment outcome studies and 54 intervention descriptions, covering a range of treatment modalities) met inclusion criteria. Most interventions are evaluated positively, while some studies lack evidence for efficacy and effectiveness. Conclusion: Scarcity of rigorous studies, diversity of interventions, and mixed results of evaluations demonstrate a need to identify evidence-based interventions. The literature presents consensus on a number of treatment-related issues, yet the application remains limited across interventions.

Context Millions of Cambodians suffered profound trauma during the Khmer Rouge era (1975 to 1979). A joint United Nations–Cambodian tribunal (the “Khmer Rouge trials”) was empanelled in 2006 to prosecute top Khmer Rouge leaders and began substantive hearings in March 2009. Objectives To establish the prevalence of probable posttraumatic stress disorder (PTSD) among adult Cambodians and to assess correlates of PTSD symptoms and disability with perceived justice, desire for revenge, and knowledge of and attitudes toward the trials. Design, Setting, and Participants A national probability sample of 1017 Cambodians was assembled using a multistage, stratified cluster design, including 813 adults older than 35 years who had been at least 3 years old during the Khmer Rouge era and 204 adults aged 18 to 35 years who had not been exposed to the Khmer Rouge era. Face-to-face interviews were conducted between December 2006 and August 2007. Main Outcome Measures Prevalence of probable PTSD using the PTSD Checklist, Civilian version (cutoff score of 44), and mental and physical disability using the Medical Outcomes Study 12-item Short Form Health Survey. Results The prevalence of current probable PTSD was 11.2% (95% confidence interval [CI], 8.6%-13.9%) overall and 7.9% (95% CI, 3.8%-12.0%) among the younger group and 14.2% (95% CI, 11.0%-17.3%) in the older group. Probable PTSD was significantly associated with mental disability (40.2% vs 7.9%; adjusted odds ratio [AOR], 7.80; 95% CI, 3.90-15.60) and physical disability (39.6% vs 20.1%; AOR, 2.60; 95% CI, 1.26-5.39). Although Cambodians were hopeful that the trials would promote justice, 87.2% (n = 681) of those older than 35 years believed that the trials would create painful memories for them. In multivariate analysis, respondents with high levels of perceived justice for violations during the Khmer Rouge era were less likely to have probable PTSD than those with low levels (7.4% vs 12.7%; AOR, 0.54; 95% CI, 0.34-0.86). Respondents with high levels of desire for revenge were more likely to have probable PTSD than those with low levels (12.0% vs 7.2%), but the difference was not statistically significant in the multivariate analysis (AOR, 1.76; 95% CI, 0.99-3.11). Conclusions Probable PTSD is common and associated with disability in Cambodia. Although Cambodians had positive attitudes toward the trials, most were concerned that the trials would bring back painful memories. Now that the trials have begun, longitudinal research is needed to determine the impact of the trials on Cambodians' mental health.

In non-Western countries, efficient and contextually valid methods of community screening are scarce. The present study describes the validation of a new, brief, 7-item multi-informant screener for conflict-affected children (Child Psychosocial Distress Screener; CPDS). To determine concurrent validity, the CPSD was administered to 65 children and their teachers. CPDS scores were compared with indication for psychosocial treatment based on an in-depth clinical assessment by a psychiatrist and psychologist. Construct validity was assessed by testing the measurement equivalence of the CPDS in a community sample (N = 2,240) in Burundi. The CPDS identifies indication for treatment with an accurateness of .81(sensitivity of .84; specificity of .60). Test?retest reliability of the instrument is good (.83). A robust and invariant factor structure provides evidence for the construct validity of the CPSD. The CPDS appears to be a useful multidimensional tool that measures nonspecific child psychosocial distress, detecting children with an indication for treatment. Because of brevity and the ability to be administered by nonspecialists, the CPDS can be an appropriate instrument to screen large populations of conflict-affected children.

Our objective was to explore the relationships between psychiatric symptom categories (posttraumatic stress disorder (PTSD), anxiety, and depression) and disability among torture survivors. We conducted a cross-sectional study of help-seeking torture survivors in highly affected conflict areas in rural mid-Western Nepal, using rating scales to assess symptomatology and disability. Validated screening instruments for the Nepali setting revealed that a high amount of psychopathology was present. Exploration of the relationships between psychiatric symptomatology and disability showed a central role for PTSD and anxiety complaints, but not for depressive complaints. A recursive model in which PTSD has (a) a direct relationship with disability and (b) an indirect relationship with disability mediated by anxiety and depression best fits the data. Findings are consistent with research on tortured refugees, suggesting the importance of a PTSD-anxiety mechanism. Implications for refugees in Western settings are discussed. Complexity of the mental status of torture survivors indicates multidisciplinary treatment.

Towards the end of civil war in Ethiopia leading to Eritrea’s independent government in 1991, a large number of persons were displaced from their homes in Eritrea, to reside in shelters in Addis Ababa. We evaluate trauma, coping, social support and sociodemographics among them particularly in relation to gender. From each randomly selected household in these shelters, a subject was interviewed, yielding 1200 subjects in all. Men, compared to women, reported significantly higher physical abuse during childhood in the family, traumatic childhood life events, experience of most traumatic life events related to displacement, and perceived social support. Women reported higher emotion-oriented coping whereas men reported higher task-oriented coping. Traumatic events were associated with higher emotion-oriented coping in both genders, and with higher task-oriented coping in women. Perceived social support was correlated positively with task-oriented coping in both genders, but was not associated with traumatic life events. Severe trauma is associated with coping and perceived social support in part differently with regards to gender. Long-term help initiatives to alleviate the psychological wounds lasting for years should incorporate these gender-specific aspects.

This study examined the cross-cultural construct equivalence of the Structured Interview for Disorders of Extreme Stress (SIDES), an instrument designed to assess symptoms of Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Participants completed the SIDES as a part of an epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence in Algeria (n = 652), Ethiopia (n = 1,200), and Gaza (n = 585). Findings indicated that the factor structure of the SIDES across samples was not stable; thus construct equivalence was not shown. A multistep interdisciplinary method is proposed to improve the cross-cultural construct validity of a psychiatric concept. This method accommodates universal chronic sequelae of extreme stress and accommodates culture-specific symptoms across a variety of cultures.

This longitudinal study evaluated the validity of earlier established predictors for postpartum posttraumatic stress (postpartum PTS) in a community sample of women (n = 248) in the Netherlands. Data was collected at 32 weeks gestation and at 3, 6 and 12 months postpartum by means of structured interviews. On the basis of the literature, an etiological model was defined with two pathways for the prediction of postpartum PTS. The model encompassed prepartum factors (e.g. depression in family, depression during life and depression during gestation), peripartum factors (e.g. type of delivery, experienced pain, social support by medical staff, supply of information and perinatal dissociation), and postpartum factors (e.g. postpartum depression). The model was evaluated by LISREL. Two pathways for postpartum PTS were confirmed: (1) delivery-related stressors predict postpartum PTS and (2) previous depression predicts postpartum PTS. Implications for mental health care during and after delivery are discussed. Copyright © 2005 John Wiley & Sons, Ltd.

Clinically, a long asylum procedure seems to be associated with psychiatric disorders. However, data on this issue are lacking. In a national community-based study, using random sampling, we compared two groups of Iraqi asylum seekers, who had resided less than 6 months (N = 143) and more than 2 years (N= 151), respectively, in The Netherlands. Respondents were interviewed with fully structured, culturally validated, translated questionnaires. Psychiatric (DSM-IV) disorders were measured with the Composite International Diagnostic Interview 2.1 and evaluated in relation with premigration and postmigration adverse life events. Overall prevalence of psychiatric disorders was 42% in the first group and 66.2% in the second. The prevalence rates of anxiety, depressive, and somatoform disorders were significantly higher in the second group. Posttraumatic stress disorder was high in both groups but did not differ (p > .05). On logistic regression of all relevant risk factors, a long asylum procedure showed an odds ratio of 2.16 (confidence interval = 1.15-4.08) for psychopathology. The conclusion is that, indeed, the duration of the asylum procedure is an important risk factor for psychiatric problems. Both politicians and mental health workers should take note of this finding.

Despite efforts to promote traditional medicine, allopathic practitioners often look with distrust at traditional practices. Shamans in particular are often regarded with ambivalence and have been considered mentally ill people. We tested the hypothesis that shamanism is an expression of psychopathology. In the Bhutanese refugee community in Nepal, a community with a high number of shamans, we surveyed a representative community sample of 810 adults and assessed ICD-10 mental disorders through structured diagnostic interviews. Approximately 7% of male refugees and 0.5% of female refugees reported being shamans. After controlling for demographic differences, the shamans did not differ from the comparison group in terms of 12-month and lifetime ICD-10 severe depressive episode, specific phobia, persistent somatoform pain, posttraumatic stress, generalized anxiety, or dissociative disorders. This first-ever, community-based, psychiatric epidemiological survey among shamans indicated no evidence that shamanism is an expression of psychopathology. The study's finding may assist in rectifying shamans' reputation, which has been tainted by past speculation of psychopathology.

Previous research has indicated a relationship between posttraumatic stress disorder (PTSD) and somatic complaints. We examined whether this relationship is a result of shared comorbidity with anxiety and depression. Local doctors interviewed a random, community sample of 526 tortured and 526 nontortured Bhutanese refugees living in U.N. refugee camps in Nepal. The interview covered demographics, torture, somatic complaints, and PTSD, depression, and anxiety measures. Number of PTSD symptoms, independent of depression and anxiety, predicted both number of reported somatic complaints and number of organ systems involving such complaints. Physicians need to screen for PTSD when survivors of extreme stressors present nonspecific somatic complaints.

Many scholars question the immense variation in rates of mental health outcomes across disaster studies. This study explains this variation by putting forward 2 methodological problems that are inherent to the effect of a disaster context on mental health screening scores. The Hopkins Symptom Checklist-25 was administered in a flood-affected group (n = 318) and a nonaffected group (n = 304) in Uttar Pradesh, India. The affected group showed much higher mean scores on subscales of anxiety and depression. However, factor analyses (i.e., confirmatory factor analyses [CFA] and multilevel confirmatory factor analyses [MCFA]; Muthen, 1994) revealed 2 methodological phenomena that account for the differences in scores. First, the outcomes revealed that a large proportion of covariance between observed mental health variables did not refer to the latent concepts of interest (depression and anxiety), but to the context of both groups (disaster affected vs. nonaffected). The shared effect of the disaster on the context explained a large proportion of the covariances between the items and biased outcomes. Second, after dissecting this group variance, the construct validity of the assessments of anxiety and depression was revealed to be poor and unstable across both groups. The subscales of anxiety and depression referred to different concepts in both groups. These 2 methodological problems have not been discussed thus far, but they contribute to the variation in mental health outcomes across disaster studies.

Background: In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi.Methods: Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external ‘gold standard’ criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL).Results: The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90.Conclusions: The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.

Background. We sought to identify personal factors that placed people at risk during an epidemic of medically unexplained illness in a Bhutanese refugee camp in southeastern Nepal.Methods. We conducted a case–control study, involving 68 cases and 66 controls. Caseness was defined as experiencing at least one attack of medically unexplained fainting or dizziness during the time of the epidemic. We performed hierarchical logistic regression analysis to identify significant predictors of case status.Results. In terms of Western psychiatric constructs, the illness involved somatoform symptoms of both acute anxiety and dissociation. Sixty per cent reported visual and 28% reported auditory hallucinatory experiences. Cases and controls were similar on all demographic variables, school performance, number of attacks witnessed and psychopathology before the onset of the epidemic. Recent loss, early loss, childhood trauma and pulse-rate were predictors of case status.Conclusion. We identified trauma, early loss and, especially, recent loss as predictors of attacks during medically unexplained epidemic illness in a Bhutanese refugee community.

Objectives. The Self-Expression and Control Scale (SECS) has been constructed to investigate the role of anger expression and anger control in the aetiology and progression of hypertension, coronary heart disease and other chronic diseases. Design and methods. This questionnaire was presented to a Dutch community sample (N = 946). A first version of the questionnaire with 64 items was reduced to 40 items on the basis of principal component analyses and analyses of internal consistency. This final 40-item version of the questionnaire consists of four subscales of 10 items each. The subscales are: anger-in (AI, the internationalization of anger), anger-out (AO, the externalization of anger), control-anger-in (CAI, control over the internalization of anger) and control-anger-out (CAO, control over the externalization of anger). Additionally, differences between the community sample of Dutch residents and a sample of coronary heart disease patients (N = 257) on the four subscales were examined. Results. The psychometric properties of the SECS proved to be highly acceptable, and the convergent and discriminant validity quite promising. Males and older persons scored statistically significantly lower on AO and higher on CAI and CAO than females and younger persons. The community sample of Dutch residents scored significantly higher on AO than a population of coronary heart disease patients. Conclusions. The anger control scales seem to allow a more differentiated assessment of anger, which may be of crucial importance for future research on anger and health.

As one article in an ongoing series on Global Mental Health Practice, Mark Jordans and colleagues describe their work developing and evaluating a community-based psychosocial and mental health care package for children in five conflict affected countries: Burundi, Indonesia, Nepal, Sri Lanka, and Sudan.

The literature on resilience in children affected by armed conflict is limited by (a) a lack of longitudinal research designs, (b) limited knowledge on transactional processes, (c) sparse findings across diverse sociocultural settings, and (d) poor theoretical development. This chapter describes four recent research projects that were aimed at overcoming some of these limitations. First, we report the findings of a longitudinal study of former child soldiers in Sierra Leone that examined risk and protective processes in psychosocial adjustment and social reintegration. Second, we describe how variables at different ecological levels contributed to outcomes on a measure of positive psychosocial well-being, developed in a participatory way with former child soldiers in Nepal. Third, we highlight the role that single-case studies can play in the development of theory regarding treatment processes, by presenting a study with children affected by armed conflict in Burundi and Sudan. Finally, we describe a study that examined mediators and moderators of intervention effects in a cluster randomized trial of a school-based intervention with children in Indonesia. These examples are meant as an illustration of how advances in longitudinal and multilevel statistics, combined with attention to theory development and a participatory context-sensitive approach, may improve understanding of the complexity of resilience of children in areas of armed conflict.

As one article in an ongoing series on Global Mental Health Practice, Mark Jordans and colleagues describe their work developing and evaluating a community-based psychosocial and mental health care package for children in five conflict affected countries: Burundi, Indonesia, Nepal, Sri Lanka, and Sudan.

Research on the mental health and psychosocial well-being of children in areas of political violence has largely focused on investigating the relation between exposure to armed conflict events and posttraumatic stress symptomatology. Comparatively little knowledge is available on protective processes in this population, which may be highly informative in the development of preventive interventions. This chapter reviews findings on resilience in children affected by political violence from a socio-ecological perspective. Despite limitations of current knowledge, the available evidence suggests that strengthening protective processes at the family level may be a fruitful preventive strategy. Furthermore, current knowledge highlights the complexity of sociocultural processes. For example, ideological commitment and religious beliefs may promote mental health but at a larger societal cost, and the promotion of traditional practices may inadvertently be associated with reinforcing stigma or marginalization. We recommend that practitioners interested in building on resilience processes start program development with context-sensitive participative assessments and commit to closely monitoring preventive interventions.

The Self-Expression and Control Scale (SECS), constructed to investigate the role of anger expression and anger control in somatic and mental diseases, was administered to patients with recurrent suicide attempts. The psychometric properties of the SECS proved to be highly acceptable and comparable with the psychometric properties of the instrument administered to a community sample. Suicide attempters scored higher on trait anger, higher on the internalization of anger and lower on both control of the internalization and the externalization of anger than controls in a community sample. Additionally, suicide attempters with a diagnosis of borderline personality disorder scored higher on the externalization of anger, and lower on both control of the internalization and the externalization of anger than suicide attempters without this diagnosis. Finally, the subgroup of patients with a psychiatric diagnosis of a“recurrent deliberate self-harm” scored higher on the internalization of anger than other patients with recurrent suicide attempts. These results show that the SECS is able to make a distinction between several subgroups of suicide attempters, and between suicide attempters and persons in a community sample with respect to the expression and control of anger. As such, the SECS can give indication for optimal psychotherapeutic treatment.

Women with antibodies against the enzyme thyroid peroxidase [TPO-Ab; formerly microsomal antibodies (MsAb)] are at particular risk for developing postpartum thyroid dysfunction; the latter is significantly associated with postpartum depression. Although the negative effect of postpartum maternal depression on child development is well documented, the consequences of elevated titers of TPO-Ab during pregnancy and subsequent postpartum thyroid dysfunction on child development are not known. In a prospective study of a cohort of 293 pregnant women, the occurrence of TPO-Ab during gestation, thyroid dysfunction, and depression was investigated. Five years after delivery, child development was assessed in 230 children of the original cohort using the Dutch translation of the McCarthy Scales of Children's Abilities. Children of women with TPO-Ab during late gestation (n = 19, with normal thyroid function) had significantly lower scores (by t test) on the McCarthy Scales of Children's Abilities than antibody-negative women. The difference on the General Cognitive Scale, which reflects IQ scores, was substantial (10.5 points; t = 2.8; P = 0.005). After correction for possibly confounding variables, maternal TPO-Ab during gestation was found to be the most important factor related to the scores on the General Cognitive Scale (odds ratio = 10.5; 95% confidence interval = 3-34; P = 0.003). We conclude that children of pregnant women who had elevated titers of TPO-Ab but normal thyroid function are at risk for impaired development.

Summary Research into postconflict psychiatric sequelae in low-income countries has been focused largely on symptoms rather than on full psychiatric diagnostic assessment. We assessed 3048 respondents from postconflict communities in Algeria, Cambodia, Ethiopia, and Palestine with the aim of establishing the prevalence of mood disorder, somatoform disorder, post-traumatic stress disorder (PTSD), and other anxiety disorders. PTSD and other anxiety disorders were the most frequent problems. In three countries, PTSD was the most likely disorder in individuals exposed to violence associated with armed conflict, but such violence was a common risk factor for various disorders and comorbidity combinations in different settings. In three countries, anxiety disorder was reported most in people who had not been exposed to such violence. Experience of violence associated with armed conflict was associated with higher rates of disorder that ranged from a risk ratio of 2·10 (95% CI 1·38–2·85) for anxiety in Algeria to 10·03 (5·26–16·65) for PTSD in Palestine. Postconflict mental health programmes should address a range of common disorders beyond PTSD.

IntroductionA principal strategy for the integration of mental health and psychosocial support in emergency settings is the training of front-line workers in international consensus-based guidelines.AimThis paper presents a pilot study evaluating changes in knowledge and understanding as a result of a brief training course in Nepal.MethodEvaluation questionnaires were distributed to participants in two-day courses (n = 109) before, directly after, and at two months following completion.ResultsThe course resulted in a post-training increase in correct answers of 21%, which further increased to 25% at two months.ConclusionA short training course based on widely endorsed guidelines to front-line staff can significantly increase mental health literacy for complex emergencies. While promising, the trend of knowledge gain is modest at most, and suggests a need for more intensive or more targeted training courses.Jordans MJD, Luitel NP, Poudyal B, Tol WA, Komproe IH. Evaluation of a brief training on mental health and psychosocial support in emergencies: a pre- and post-assessment in Nepal. Prehosp Disaster Med. 2012;27(3):1-4.