This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (IC... more There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community stakeholders, ICBT clinicians, managers, and researchers, was formed. The working group examined archival feedback on ICBT from past clients who self-identified as being from diverse ethnocultural back-grounds (N=278) and results of interviews with current patients (N=16), community stakeholders (N=6), and clinicians (N=3). The archival data and interviews revealed the majority of the pa-tients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT ...
Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is kn... more Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is known about the challenges clients face during ICBT, such as difficulties with skill practice, development, or maintenance. Understanding client difficulties can help therapists support clients with skill development and prevent treatment drop-out, but has not been systematically studied. This study included a conventional content analysis of clients’ responses to a homework reflection question about difficulties with lessons and skills. Data was drawn from a previously published trial of 301 clients who were randomly assigned to receive homework reflection questions during ICBT. A decreasing number of clients responded to the question about skill difficulties with each lesson. Clients who answered the question about difficulties were more engaged with ICBT (i.e., more lessons completed, logins, days enrolled in ICBT, and messages sent to therapists). Clients shared skill-specific challeng...
Background Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental ... more Background Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental disorder of the COVID-19 pandemic, assuming that PTSD’s life-threat criterion was met de facto. More plausible outcomes like adjustment disorder (AD) have been overlooked. Methods An online cross-sectional survey was launched in the initial stage of the pandemic using a convenience sample of 5 913 adults to compare the prevalence of COVID-related probable PTSD versus probable AD. The abridged Impact of Event Scale – Revised (IES-6) assessed the severity of trauma- and stressor-related symptoms over the previous week. Demographic and pandemic-related data (e.g., receiving a formal diagnosis of COVID-19, job loss, loss of loved one, confinement, material hardship) were collected. A Classification and Regression Tree analysis was conducted to uncover the pandemic experiences leading to clinical ‘caseness’. Caseness was defined by a score > 9 on the IES-6 symptom measure and further chara...
Recently, this journal published an article by Sariaslan, Leucht, Zetterqvist, Lichtenstein, and ... more Recently, this journal published an article by Sariaslan, Leucht, Zetterqvist, Lichtenstein, and Fazel (2021), which describes a cohort of individuals prescribed antipsychotics in Sweden between 2005 and 2013. The authors provide a methodologically rigorous study with a large sample (n = 74 925) from several national databases that control for time-invariant confounders (e.g. demographic characteristics). They conclude that periods of absence of antipsychotic prescription among individuals with psychotic disorders are associated with higher rates of arrests and convictions (Sariaslan et al., 2021). We applaud Sariaslan et al. for their clever study design but have several concerns and questions about the motives and message of the paper. We found that they did not sufficiently cover the complex background of literature on antipsychotic prescription, which weakens their supposition of covering time-invariant factors. Their broadly defined constructs, such as 'crime rates', also seemed misleading. They furthermore may stigmatize mental illness by promoting antipsychotics as a criminogenic intervention. For one, the paper concludes that antipsychotics may effectively reduce arrests and convictions in patients with psychotic disorders. However, they ignore important social and environmental factors that confound these conclusions. For instance, a foundational study in the World Journal of Psychiatry (Schwartz & Blankenship, 2014) established that Black and African American healthcare consumers are diagnosed with psychotic disorders at a rate three or four times higher than White consumerswith a similar trend for immigrants In Sweden, these findings hold; Black citizens and immigrants receive psychotic disorder diagnoses at a higher rate and are more likely to be compulsorily admitted (e.g. Al-Saffar, Borga, Wicks, & Hallstrom, 2004). The racial bias in the mental health system and policing puts into question both the ecological validity and implications of the observed betweenperson associations. The current climate in Sweden regarding race and immigration is also an important consideration. Some believe that immigrants increase crimethough they have decreasing rates of crime and face several challenges integrating into society (Vasiljevic, Svensson, & Shannon, 2020). Thus, these researchers had a crucial task to carefully consider the literature as not to advance stereotypes or prejudices. Sariaslan et al. also seem to causally link the use of individual antipsychotics to decreasing arrests and convictions. Nevertheless, this study is observational and only associations are present. The study does not account for several time-variant covariates such as vulnerability/medical delay situations linked to the absence of prescription. Equally, some analyses appear underpowered (e.g. clozapine's association with arrests and convictions). Despite these limitations, the authors infer causation, discussing potential mechanisms of individual antipsychotics such as clozapine. Sariaslan et al. even suggest that these associations could sway clinical decision-making, which in both cases are conclusions much ahead of the presented evidence. Several methodological limitations must be considered since the study used measures such as arrest and convictions. The authors refer to these measures as 'crime rates', which is a misnomer. We should not conflate arrest and conviction rates with crime rates. There are many biases in criminal justice toward individuals with mental illnesses. Individuals with mental illnesses are perceived as dangerous, more prone to arrest or detention, and more prone to victimization or death by police (independent of criminogenic factors) (
Background Traumatic stress is a global mental health problem requiring novel, easily implemented... more Background Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country. Methods Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks. Results An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (β1 = − 4.83, 95% CI = [− 5.66, − 4.01], p < .001), whereby both groups improved, with Cohen’s effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of ...
This paper presents the first systematic case-control study of correlates of mass psychogenic ill... more This paper presents the first systematic case-control study of correlates of mass psychogenic illness (MPI) in an adolescent school population. MPI is generally construed as a dissociative phenomenon spread by social contagion to individuals who are prone to dissociation. We sought to test if the correlates of dissociative experiences most commonly proposed in the literature could predict caseness among students affected by episodes of mass psychogenic illness occurring in schools in Nepal. We assessed 194 cases and 190 controls (N = 384) of ages 11-18 years from 12 public schools. Cases and controls were comparable on all demographic variables, except for family configuration, with nuclear families more common among those affected. In bivariate comparisons, caseness was associated with childhood physical neglect and abuse, as well as living in nuclear families, peritraumatic dissociation, dissociative tendencies, and depressive and post-traumatic stress symptoms. Hypnotizability emerged as the strongest correlate of psychogenic illness among the cognitive and personality trait variables. However, in multivariable logistic regression, the correlates of dissociation did not predict caseness, suggesting that they do not adequately account for the phenomenon of mass psychogenic illness. An ad-hoc Classification and Regression Trees analysis showed that if an adolescent was highly hypnotizable and reported high rates of peritraumatic dissociative experiences, then there was a 73% probability of being a case in a mass psychogenic illness episode. Future studies involving other psychological, social and cultural factors, as well as school-and family-related factors are needed to understand the correlates of mass psychogenic illness and guide prevention and intervention.
Background and Objectives: Nepal has witnessed several periods of organized violence since its be... more Background and Objectives: Nepal has witnessed several periods of organized violence since its beginnings as a sovereign nation. Most recently, during the decade-long Maoist Conflict (1996-2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. Moreover, there is widespread gender-, ethnic-and castebased discrimination, and grossly unequal distribution of wealth in the country. While the immediate mental health effects of the conflict are well studied, less is known about the long-term effects of the conflict. This article sets out to explain how Nepalese survivors of violence perceive their wellbeing and mental health, search for help and construct their health care pathways and therapeutic itineraries. The aim is to provide a better understanding of local explanatory models and healthcare behaviors. Methods: Semi-structured interviews were carried out with 25 people (14 men, 11 women) aged 30 to 65 in Dang district in 2013. To elicit illness narratives, a translated and culturally adapted version of the McGill Illness Narrative Interview (MINI) was used. Additionally, participants were interviewed about their war experiences and present-day economic and social situations. The transcripts were coded using deductive and inductive approaches and analyzed through thematic analysis. Results: The study provides insight into temporal narratives of illness experience and explanatory modules. Symptoms were found to be widespread and varied, and were not solely attributed to violent experiences and memories, but also to everyday stressors related to survivors' economic, social, and familial situations. In terms of help-and health-seeking behavior it was found that participants resorted to various coping strategies such as social activities, avoidance, withdrawal, and substance use. Many participants had received biomedical treatment for their psychosocial problems from doctors and specialists working in public and private sector clinics and hospitals as well as different forms of traditional healing. Conclusions: These results shed light on the long-term impact of the Nepalese conflict on survivors of extreme violence, highlighting local explanatory models and help-and
Efforts to address global mental health disparities have given new urgency to longstanding debate... more Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scoping review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom...
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews ( n = 40, camp community; n = 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, al...
In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic ill... more In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews (n ¼ 40, camp community; n ¼ 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to helpseeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the ''heart-mind'' and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts.
Efforts to address global mental health disparities have given new urgency to longstanding debate... more Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scop-ing review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.
In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. T... more In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. To identify the cultural contexts and psychosocial correlates of spirit possession, we conducted a mixed-method study in a village in central Nepal experiencing a cluster of spirit possession events. The study was carried out in three stages: (1) a pilot study consisting of informal interviews with possessed individuals, observations of the possession spells, and video recording of possession events; (2) a case-control study comparing the prevalence of symptoms of common mental disorders in women who had and had not experienced possession; and (3) a follow-up study with focus group discussions and in-depth interviews with possessed and non-possessed men and women, and key informants. Quantitative results indicated that possessed women reported higher rates of traumatic events and higher levels of symptoms of mental disorder compared to non-possessed women (Anxiety 68 vs. 18 %, Depression 41 vs. 19 %, and PTSD 27 vs. 0 %). However, qualitative interviews with possessed individuals, family members, and traditional healers indicated that they did not associate possession states with mental illness. Spirit possession was viewed as an affliction that provided a unique mode of communication between humans and spirits. As such, it functioned as an idiom of distress that allowed individuals to express suffering related to mental illness, sociopolitical violence, traumatic events, and the oppression of women. The study results clearly indicate that spirit possession is a multi-dimensional phenomenon that cannot be mapped onto any single psychiatric or psychological diagnostic category or construct. Clinical and public health efforts to address spirit possession must take the socio-cultural context and systemic dynamics into account to avoid creating iatrogenic illness, undermining coping strategies, and exacerbating underlying social problems.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (IC... more There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community stakeholders, ICBT clinicians, managers, and researchers, was formed. The working group examined archival feedback on ICBT from past clients who self-identified as being from diverse ethnocultural back-grounds (N=278) and results of interviews with current patients (N=16), community stakeholders (N=6), and clinicians (N=3). The archival data and interviews revealed the majority of the pa-tients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT ...
Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is kn... more Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is known about the challenges clients face during ICBT, such as difficulties with skill practice, development, or maintenance. Understanding client difficulties can help therapists support clients with skill development and prevent treatment drop-out, but has not been systematically studied. This study included a conventional content analysis of clients’ responses to a homework reflection question about difficulties with lessons and skills. Data was drawn from a previously published trial of 301 clients who were randomly assigned to receive homework reflection questions during ICBT. A decreasing number of clients responded to the question about skill difficulties with each lesson. Clients who answered the question about difficulties were more engaged with ICBT (i.e., more lessons completed, logins, days enrolled in ICBT, and messages sent to therapists). Clients shared skill-specific challeng...
Background Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental ... more Background Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental disorder of the COVID-19 pandemic, assuming that PTSD’s life-threat criterion was met de facto. More plausible outcomes like adjustment disorder (AD) have been overlooked. Methods An online cross-sectional survey was launched in the initial stage of the pandemic using a convenience sample of 5 913 adults to compare the prevalence of COVID-related probable PTSD versus probable AD. The abridged Impact of Event Scale – Revised (IES-6) assessed the severity of trauma- and stressor-related symptoms over the previous week. Demographic and pandemic-related data (e.g., receiving a formal diagnosis of COVID-19, job loss, loss of loved one, confinement, material hardship) were collected. A Classification and Regression Tree analysis was conducted to uncover the pandemic experiences leading to clinical ‘caseness’. Caseness was defined by a score > 9 on the IES-6 symptom measure and further chara...
Recently, this journal published an article by Sariaslan, Leucht, Zetterqvist, Lichtenstein, and ... more Recently, this journal published an article by Sariaslan, Leucht, Zetterqvist, Lichtenstein, and Fazel (2021), which describes a cohort of individuals prescribed antipsychotics in Sweden between 2005 and 2013. The authors provide a methodologically rigorous study with a large sample (n = 74 925) from several national databases that control for time-invariant confounders (e.g. demographic characteristics). They conclude that periods of absence of antipsychotic prescription among individuals with psychotic disorders are associated with higher rates of arrests and convictions (Sariaslan et al., 2021). We applaud Sariaslan et al. for their clever study design but have several concerns and questions about the motives and message of the paper. We found that they did not sufficiently cover the complex background of literature on antipsychotic prescription, which weakens their supposition of covering time-invariant factors. Their broadly defined constructs, such as 'crime rates', also seemed misleading. They furthermore may stigmatize mental illness by promoting antipsychotics as a criminogenic intervention. For one, the paper concludes that antipsychotics may effectively reduce arrests and convictions in patients with psychotic disorders. However, they ignore important social and environmental factors that confound these conclusions. For instance, a foundational study in the World Journal of Psychiatry (Schwartz & Blankenship, 2014) established that Black and African American healthcare consumers are diagnosed with psychotic disorders at a rate three or four times higher than White consumerswith a similar trend for immigrants In Sweden, these findings hold; Black citizens and immigrants receive psychotic disorder diagnoses at a higher rate and are more likely to be compulsorily admitted (e.g. Al-Saffar, Borga, Wicks, & Hallstrom, 2004). The racial bias in the mental health system and policing puts into question both the ecological validity and implications of the observed betweenperson associations. The current climate in Sweden regarding race and immigration is also an important consideration. Some believe that immigrants increase crimethough they have decreasing rates of crime and face several challenges integrating into society (Vasiljevic, Svensson, & Shannon, 2020). Thus, these researchers had a crucial task to carefully consider the literature as not to advance stereotypes or prejudices. Sariaslan et al. also seem to causally link the use of individual antipsychotics to decreasing arrests and convictions. Nevertheless, this study is observational and only associations are present. The study does not account for several time-variant covariates such as vulnerability/medical delay situations linked to the absence of prescription. Equally, some analyses appear underpowered (e.g. clozapine's association with arrests and convictions). Despite these limitations, the authors infer causation, discussing potential mechanisms of individual antipsychotics such as clozapine. Sariaslan et al. even suggest that these associations could sway clinical decision-making, which in both cases are conclusions much ahead of the presented evidence. Several methodological limitations must be considered since the study used measures such as arrest and convictions. The authors refer to these measures as 'crime rates', which is a misnomer. We should not conflate arrest and conviction rates with crime rates. There are many biases in criminal justice toward individuals with mental illnesses. Individuals with mental illnesses are perceived as dangerous, more prone to arrest or detention, and more prone to victimization or death by police (independent of criminogenic factors) (
Background Traumatic stress is a global mental health problem requiring novel, easily implemented... more Background Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country. Methods Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks. Results An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (β1 = − 4.83, 95% CI = [− 5.66, − 4.01], p < .001), whereby both groups improved, with Cohen’s effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of ...
This paper presents the first systematic case-control study of correlates of mass psychogenic ill... more This paper presents the first systematic case-control study of correlates of mass psychogenic illness (MPI) in an adolescent school population. MPI is generally construed as a dissociative phenomenon spread by social contagion to individuals who are prone to dissociation. We sought to test if the correlates of dissociative experiences most commonly proposed in the literature could predict caseness among students affected by episodes of mass psychogenic illness occurring in schools in Nepal. We assessed 194 cases and 190 controls (N = 384) of ages 11-18 years from 12 public schools. Cases and controls were comparable on all demographic variables, except for family configuration, with nuclear families more common among those affected. In bivariate comparisons, caseness was associated with childhood physical neglect and abuse, as well as living in nuclear families, peritraumatic dissociation, dissociative tendencies, and depressive and post-traumatic stress symptoms. Hypnotizability emerged as the strongest correlate of psychogenic illness among the cognitive and personality trait variables. However, in multivariable logistic regression, the correlates of dissociation did not predict caseness, suggesting that they do not adequately account for the phenomenon of mass psychogenic illness. An ad-hoc Classification and Regression Trees analysis showed that if an adolescent was highly hypnotizable and reported high rates of peritraumatic dissociative experiences, then there was a 73% probability of being a case in a mass psychogenic illness episode. Future studies involving other psychological, social and cultural factors, as well as school-and family-related factors are needed to understand the correlates of mass psychogenic illness and guide prevention and intervention.
Background and Objectives: Nepal has witnessed several periods of organized violence since its be... more Background and Objectives: Nepal has witnessed several periods of organized violence since its beginnings as a sovereign nation. Most recently, during the decade-long Maoist Conflict (1996-2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. Moreover, there is widespread gender-, ethnic-and castebased discrimination, and grossly unequal distribution of wealth in the country. While the immediate mental health effects of the conflict are well studied, less is known about the long-term effects of the conflict. This article sets out to explain how Nepalese survivors of violence perceive their wellbeing and mental health, search for help and construct their health care pathways and therapeutic itineraries. The aim is to provide a better understanding of local explanatory models and healthcare behaviors. Methods: Semi-structured interviews were carried out with 25 people (14 men, 11 women) aged 30 to 65 in Dang district in 2013. To elicit illness narratives, a translated and culturally adapted version of the McGill Illness Narrative Interview (MINI) was used. Additionally, participants were interviewed about their war experiences and present-day economic and social situations. The transcripts were coded using deductive and inductive approaches and analyzed through thematic analysis. Results: The study provides insight into temporal narratives of illness experience and explanatory modules. Symptoms were found to be widespread and varied, and were not solely attributed to violent experiences and memories, but also to everyday stressors related to survivors' economic, social, and familial situations. In terms of help-and health-seeking behavior it was found that participants resorted to various coping strategies such as social activities, avoidance, withdrawal, and substance use. Many participants had received biomedical treatment for their psychosocial problems from doctors and specialists working in public and private sector clinics and hospitals as well as different forms of traditional healing. Conclusions: These results shed light on the long-term impact of the Nepalese conflict on survivors of extreme violence, highlighting local explanatory models and help-and
Efforts to address global mental health disparities have given new urgency to longstanding debate... more Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scoping review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom...
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews ( n = 40, camp community; n = 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, al...
In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic ill... more In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews (n ¼ 40, camp community; n ¼ 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to helpseeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the ''heart-mind'' and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts.
Efforts to address global mental health disparities have given new urgency to longstanding debate... more Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scop-ing review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.
In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. T... more In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. To identify the cultural contexts and psychosocial correlates of spirit possession, we conducted a mixed-method study in a village in central Nepal experiencing a cluster of spirit possession events. The study was carried out in three stages: (1) a pilot study consisting of informal interviews with possessed individuals, observations of the possession spells, and video recording of possession events; (2) a case-control study comparing the prevalence of symptoms of common mental disorders in women who had and had not experienced possession; and (3) a follow-up study with focus group discussions and in-depth interviews with possessed and non-possessed men and women, and key informants. Quantitative results indicated that possessed women reported higher rates of traumatic events and higher levels of symptoms of mental disorder compared to non-possessed women (Anxiety 68 vs. 18 %, Depression 41 vs. 19 %, and PTSD 27 vs. 0 %). However, qualitative interviews with possessed individuals, family members, and traditional healers indicated that they did not associate possession states with mental illness. Spirit possession was viewed as an affliction that provided a unique mode of communication between humans and spirits. As such, it functioned as an idiom of distress that allowed individuals to express suffering related to mental illness, sociopolitical violence, traumatic events, and the oppression of women. The study results clearly indicate that spirit possession is a multi-dimensional phenomenon that cannot be mapped onto any single psychiatric or psychological diagnostic category or construct. Clinical and public health efforts to address spirit possession must take the socio-cultural context and systemic dynamics into account to avoid creating iatrogenic illness, undermining coping strategies, and exacerbating underlying social problems.
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