Papers by Bhogendra Sharma
counsellors as conducted by the Centre for Victims of Torture, Nepal. Both the proceedings of the... more counsellors as conducted by the Centre for Victims of Torture, Nepal. Both the proceedings of the training and the content are described. For clarity purposes a division is made between that part of the training in which skills are taught that can be used with more frequently encountered problems and that part of the training that deals with problems requiring a more specialised approach, such as HIV AIDS.
Background: Most refugees live in low-income countries. More than one hundred thousand Bhutanese ... more Background: Most refugees live in low-income countries. More than one hundred thousand Bhutanese refugees have been living in Nepal for several years. The association of torture and psychiatric morbidity with disability among such refugees is unknown. It is also important to understand how they perceive mental illness and disability. Objectives: (a) To compare disability between tortured and non-tortured Bhutanese refugees living in Nepal, (b) to investigate psychiatric comorbidity and its association with disability among tortured Bhutanese refugees, (c) to identify predictors of psychiatric disability among Bhutanese refugees living in Nepal, and (d) to assess their knowledge, attitude and practices regarding mental illness and disability Design and participants: Cross-sectional survey was carried out on a sample of 418 tortured and 392 non-tortured refugees, matched on age and sex. Furthermore, focus group discussions were conducted with 14 mentally ill or disabled refugees, 16 family members and 12 traditional healers in addition to 10 in-depth interviews. Settings: Bhutanese refugee camps in eastern Nepal. Main Outcome Measure: Composite International Diagnostic Interview-2.1, and Psychiatric Disability Assessment Schedule-Short (WHO DAS-S) were used to measure psychopatholgy and disability respectively. Results: Disability among tortured and non-tortured Bhutanese refugees was not significantly different (21% vs 24%, p = 0.407). Comorbidity of PTSD with persistent pain, specific phobia and dissociative disorders among tortured refugees were significantly associated with disability. Posttraumatic stress disorder (OR 2.0, 95% CI of 1.2-3.5), specific phobia (OR 2.2, 95% CI of 1.2-3.8), and present physical illness (OR 2.0, 95% CI of 1.1-3.8) were identified as predictors of disability for tortured refugees. On the other hand, generalized anxiety disorder (OR 3.3, 95% CI 1.2-9.3), older age (OR 2.3, 95% CI 1.1-5.1), and present illness (OR 2.9, 95% CI 1.7-5.2) were identified as predictors of disability for non-tortured refugees. Bhutanese refugees have specific ways of understanding and explaining mental illness and disability. Both mental illness and disability are associated with stigma in this community. Furthermore, most of them believe that mental illness could lead to disturbances in different roles. Conclusion: Disability was associated with different risk factors for tortured and nontortured refugees. Comorbidity increased odds for disability. Further studies are needed to generalize findings beyond the Bhutanese refugee population. A combination of quantitative and qualitative research provides a more in-depth picture of the nature and extent of disorders and disability than either research method is able to provide alone. xi 1.0 INTRODUCTION 1.1 Mental health The World Health Organisation (WHO) has estimated that today as many as 1500 million people worldwide are suffering at any given time from some kind of neuro-psychiatric disorders, including mental, behavioural and substance abuse disorder. A third may be affected by more than one neuro-psychiatric ailment and three quarters live in developing countries. The impact of mental illness in psychological, social and economic terms is very high. Moreover, at least one out of four people who come to health services for help is troubled by mental disorders, which are often neither correctly diagnosed nor treated (WHO, 2000). Even then, the basic epidemiological data on the prevalence and distribution of mental and behaviour health conditions is severely lacking in many low-income countries. Clinical and community epidemiological studies are needed to fill these gaps (Desjaralais et al, 1995). Furthermore, although mental health services have been developed in many countries, research activities have not often been incorporated in their planning (Tantam, 1996). There is a lack of reliable epidemiological data regarding the extent and distribution of mental disorder in the developing world. 1.2 Refugee and mental health There are currently 11.5 million refugees in this world, and the majority of them live in poor developing countries (United Nations High Commission for Refugees, 2000). It is estimated that 4.7 million refugees live in Asia alone. Many refugees are at high risk for mental health problems as a direct result of the refugee experience. Primary factors leading to this increased risk are war or trauma experience and displacement. Even a brief contact with war or trauma can have a lasting effect on a person. So far available literature on refugee mental health is by far limited to refugees living in the west (Desjaralais et al, 1995) despite the fact that majority refugee population live in low-income countries. Thus, there is a strong need of a study of mental health among refugees living in the developing countries. 1.3 Disability and mental illness WHO and ICIDH (International Classification of Impairments, Disabilities and Handicaps) have defined disability as "any restriction or lack resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal depending upon age, sex, and social and cultural factors for that individual". The WHO estimates that about 40 million people in the world have significant disabilities secondary to chronic mental health problems. Until 1993, when the concepts of Global Burden of Disease emerged, mortality measurement was the only way of determination of the burden of diseases. Since then, public health burden of an illness or disorder has been measured in terms of Disability Adjusted Life Years (DALY). One DALY is one lost year of healthy life. The estimated percentage of DALYs lost by mental health problems is 11.5%. It is also of great significance that 5 of the 10 leading causes of disability worldwide are mental health problems. These are major depression, schizophrenia, bipolar disorders, alcohol abuse, and obsessive compulsive disorders (WHO, 1999). The situation is likely to be worse among
Social Psychiatry and Psychiatric Epidemiology, 2012
Journal of Traumatic Stress, 2002
Previous research has indicated a relationship between posttraumatic stress disorder (PTSD) and s... more 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.
International Journal of Social Psychiatry, 2009
Background: Little is known about the effectiveness of treatment for torture survivors in low-inc... more Background: Little is known about the effectiveness of treatment for torture survivors in low-income settings. Multi-disciplinary treatment is an often used approach for this target group. Aims: This study was aimed at examining the effectiveness of brief multi-disciplinary treatment for torture survivors in Nepal. Methods: A naturalistic comparative design with help-seeking torture survivors and internally displaced persons assigned to a treatment and a comparison group respectively ( n = 192; treatment group n = 111, comparison group n = 81), with baseline measurements on psychiatric symptomatology, disability, and functioning and a five-month follow-up ( n = 107; treatment group n = 62; comparison group n = 45), was employed. Intervention consisted of brief psychosocial services, minimal medical services and/or legal assistance. Results: Study groups were generally comparable and non-completers did not significantly differ from completers. The treatment group improved more than t...
This paper describes the training of psychosocial counsellors as it is conducted by the Centre fo... more This paper describes the training of psychosocial counsellors as it is conducted by the Centre for Victims of Torture, Nepal. Both the proceedings of the training and the content will be described. For clarit y purposes a generic division is made between that part of the training in which skills are taught that can be used with more frequently encountered problems and that part of the training that deals with problems requiring a more specialised approach.
Transcultural Psychiatry, 1999
Preparing instruments for transcultural research is a difficult task. Researchers typically do no... more Preparing instruments for transcultural research is a difficult task. Researchers typically do not publish their attempts to create equivalent translation. The quality of the translation depends mostly on the translators’ ability to be consistent in identifying and correcting incomprehensible, unacceptable, incomplete and irrelevant translated items. This paper presents a translation monitoring form to enhance the methodical preparation of instruments for transcultural use. Use of the form requires the systematic use of strategies advocated by previous translation and adaptation researchers. A detailed example of use of the translation monitoring form with Nepali-speaking Bhutanese refugees illustrates the usefulness of the form as well as the difficulties of creating equivalent translation.
Transcultural Psychiatry, 2000
The probe flow chart of the Composite International Diagnostic Interview (CIDI) was designed to a... more The probe flow chart of the Composite International Diagnostic Interview (CIDI) was designed to assess psychiatric somatic complaints in various cultures. The CIDI’s probe flow chart does not appear to function properly in the Nepali context as the chart contains two assumptions that do not hold in Nepali culture, namely that: (i) respondents attribute their symptoms to mental, physical or substance-related processes, and (ii) doctors communicate diagnoses to their patients. The cultural validity of the CIDI is questioned.
Transcultural Psychiatry, 2005
This article describes the way in which the practice of psychosocial counselling was adapted cult... more This article describes the way in which the practice of psychosocial counselling was adapted culturally to the context of Nepal within the Centre for Victims of Torture, Nepal (CVICT). After a brief description of the Nepali setting and CVICT's counselling and training approach and the relationship of its psychosocial counselling intervention with existing methods of dealing with psychosocial problems, the cultural challenges of implementing psychosocial counselling and our response to them are sketched along with concepts deemed important in psychosocial counselling. A discussion follows in which the authors' stance on the export of psychosocial counselling to non-western cultures is outlined. Key words adaptation • cross-cultural • non-western • psychosocial counselling • training Since 1996 a violent conflict has surged in the Himalayan kingdom of Nepal as a result of a Maoist insurgency called 'the People's War.' Both government forces and Maoists are grossly violating human rights on a
Transcultural Psychiatry, 1998
Preventing torture and rehabilitating survivors in a country that practices torture is difficult ... more Preventing torture and rehabilitating survivors in a country that practices torture is difficult but possible. The Center for the Victims of Torture Nepal (CVICT) documents and treats torture survivors in four ways: (a) fact-finding teams, (b) referrals to its clinic in Kathmandu, (c) prison visits, and (d) a community-based rehabilitation program for Bhutanese refugees. In addition, the center also conducts research in four ways: (a) a quantitative matched-control study of tortured refugees to identify consequences of torture, (b) a case note survey, (c) a narrative study to identify local idioms of distress, and (d) focus groups to identify issues pertinent in the local context.
The Springer Series in Social/Clinical Psychology
... MARK VAN OMMEREN, BHOGENDRA SHARMA, DINESH PRASAIN, and BHAVA N. POUDYAL BACKGROUND ... In 19... more ... MARK VAN OMMEREN, BHOGENDRA SHARMA, DINESH PRASAIN, and BHAVA N. POUDYAL BACKGROUND ... In 1991, when large numbers of Nepali-speaking tortured Bhutanese refugees entered Nepal, CVICT organized services. ...
Psychological Medicine, 2001
Background. We sought to identify personal factors that placed people at risk during an epidemic ... more 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...
The Lancet, 1997
factors not mentioned by Tichonova and co-workers are important in the increase of STDs. In these... more factors not mentioned by Tichonova and co-workers are important in the increase of STDs. In these countries there was no free flow of information so the climate did not exist for the discussion of healthy sexuality which would enable young people, prostitutes, and homosexual men to liaise with health professionals. Condoms have not been easily available. Although some specialists in Russia are highly motivated, most are poorly skilled by western standards, often in dead-end jobs and using ancient techniques. Many scientific advances have not been disseminated. Although the use of benzathine penicillin is mentioned, I have seen outmoded penicillin regimens administered that require patients to be admitted and incarcerated for weeks on end. Difficult political times have also meant that senior specialists and opinion makers have been cautious about what they are willing to say about the epidemics. The epidemic is not only in Russia, my personal observation in Eastern Poland in September, 1996, suggests that it is spreading rapidly, together with HIV, into neighbouring countries. The community of health professions in the west need to respond urgently to this crisis and cooperate in essential help.
The Lancet, 2002
1. Lancet. 2002 Apr 27;359(9316):1519. Physicians persecuted for ethical practice in Nepal. Sharm... more 1. Lancet. 2002 Apr 27;359(9316):1519. Physicians persecuted for ethical practice in Nepal. Sharma GK, Osti B, Sharma B. Centre for Victims of Torture (CVICT), Nepal GPO Box 5839, Kathmandu, Nepal. PMID: 11988269 [PubMed - indexed for MEDLINE] MeSH Terms: ...
Journal of Nervous & Mental Disease, 2007
Our objective was to explore the relationships between psychiatric symptom categories (posttrauma... more 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.
Journal of Nervous & Mental Disease, 2004
Despite efforts to promote traditional medicine, allopathic practitioners often look with distrus... more 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.
JAMA, 1998
Context.-Most of the world's refugees are displaced within the developing world. The impact of to... more Context.-Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown. Objective.-To examine the impact of torture on Bhutanese refugees in Nepal. Design.-Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression. Setting.-Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal. Participants.-A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex. Main Outcome Measures.-The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety. Results.-The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-R PTSD symptoms (PϽ.005) and had higher HSCL-25 anxiety and depression scores (PϽ.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system-and respiratory system-related complaints (PϽ.001 for both). Conclusion.-Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.
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Papers by Bhogendra Sharma