Changes in mental disorder prevalence among conflict-affected populations: a prospective study in Sri Lanka (COMRAID-R)

Protocol of a randomised clinical trial to integrate mental health services into primary care for postconflict populations in Northern Sri Lanka (COMGAP-S)

INTRODUCTION

Sri Lanka has a long history of armed conflict and natural disasters increasing the risk of mental health disorders in the population. Due to a lack of specialist services, there is a treatment gap between those seeking and those able to access mental health services. The aim of this research programme is to integrate mental health services into primary care to meet the needs of this postconflict population.

METHODS AND ANALYSIS

This is a stepped wedge cluster design randomised clinical trial of the WHO mental health Gap Action Programme primary care mental health training intervention. We will provide a 10-day training to primary care practitioners of 23 randomly selected primary care facilities aimed at increasing their ability to identify, treat and manage common mental health disorders. Public health professionals and community representatives will receive a tailored training intervention to increase mental health awareness. Refresher courses will occur at 3 and 6 months post training. Supervision and monitoring will occur for 1 month pre and post training. Target sample sizes have been calculated separately for each group of participants and for each outcome.

ETHICS AND DISSEMINATION

This trial has received ethical approval from the Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, UK (SC/jc/FMFREP/16/17 076) and from the Faculty of Medicine, University of Jaffna, Sri Lanka (J/ERC/17/81/NDR/0170) and non-engagement approval has been received from the funding body, the Centers for Disease Control and Prevention (2018-015). All participants gave written consent. Dissemination of study results will be completed through publication of academic articles, conference presentations, town hall meetings, written pamphlets in plain language, reports to Ministry of Health and other government organisations and through social media outlets.

TRIAL REGISTRATION NUMBERS

ISRCTN registry: ISRCTN62598070. SLCTR registration number: SLCTR/2018/008.

Prevalence of mental disorders and epidemiological associations in post-conflict primary care attendees: a cross-sectional study in the Northern Province of Sri Lanka

BACKGROUND

Experiencing conflict and displacement can have a negative impact on an individual's mental health. Currently, prevalence of mental health disorders (MHDs) at the primary care level in post-conflict areas within the Northern Province of Sri Lanka is unknown. We aimed to explore this prevalence in conflict-affected populations attending primary care, using a structured package of validated screening tools for MHDs.

METHODS

This cross-sectional study aimed to determine factors related to mental health disorders at the primary care level in Northern Province, Sri Lanka. A structured interview was conducted with internally displaced adults attending 25 randomly selected primary care facilities across all districts of Northern Sri Lanka (Jaffna, Mannar, Mullaitivu, Vavuniya). Participants were screened for depression, anxiety, psychosis, PTSD, and somatoform symptoms.

RESULTS

Among 533 female and 482 male participants (mean age 53.2 years), the prevalence rate for any MHD was 58.8% (95% CI, 53.8-61.4), with 42.4% screening positive for two or more disorders (95% CI, 38.6-46.1). Anxiety prevalence was reported at 46.7% (95% CI, 41.9-51.5), depression at 41.1% (95% CI, 38.7-44.5), PTSD at 13.7% (95% CI, 10.6-16.8), somatoform symptoms at 27.6% (95% CI, 23.6-31.5), and psychosis with hypomania at 17.6% (95% CI, 13.3-21.9).

CONCLUSION

This is the first study at the primary care level to investigate prevalence of MHDs among conflict-affected populations in the Northern Province, Sri Lanka. Results highlight unmet mental health needs in the region. Training intervention to integrate mental health services into primary care is planned.

Health status of returning refugees, internally displaced persons, and the host community in a post-conflict district in northern Sri Lanka: a cross-sectional survey

Background

Although the adverse impacts of conflict-driven displacement on health are well-documented, less is known about how health status and associated risk factors differ according to displacement experience. This study quantifies health status and quality of life among returning refugees, internally displaced persons, and the host community in a post-conflict district in Northern Sri Lanka, and explores associated risk factors.

Methods

We analysed data collected through a household survey (n = 570) in Vavuniya district, Sri Lanka. The effect of displacement status and other risk factors on perceived quality of life as estimated from the 36-item Short Form Questionnaire, mental health status from 9-item Patient Health Questionnaire, and self-reported chronic disease status were examined using univariable analyses and multivariable regressions.

Results

We found strong evidence that perceived quality of life was significantly lower for internally displaced persons than for the host community and returning refugees, after adjusting for covariates. Both mental health status and chronic disease status did not vary remarkably among the groups, suggesting that other risk factors might be more important determinants of these outcomes.

Conclusions

Our study provides important insights into the overall health and well-being of the different displaced sub-populations in a post-conflict setting. Findings reinforce existing evidence on the relationship between displacement and health but also highlight gaps in research on the long-term health effects of prolonged displacement. Understanding the heterogeneity of conflict-affected populations has important implications for effective and equitable humanitarian service delivery in a post-conflict setting.

A comparative study of psychotic and affective symptoms in Rwandan and Kenyan students

AIMS

War and conflict are known to adversely affect mental health, although their effects on risk symptoms for psychosis development in youth in various parts of the world are unclear. The Rwandan genocide of 1994 and Civil War had widespread effects on the population. Despite this, there has been no significant research on psychosis risk in Rwanda. Our goal in the present study was to investigate the potential effects of genocide and war in two ways: by comparing Rwandan youth born before and after the genocide; and by comparing Rwandan and Kenyan adolescents of similar age.

METHODS

A total of 2255 Rwandan students and 2800 Kenyan students were administered the Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen. Prevalence, frequency and functional impairment related to affective and psychosis-risk symptoms were compared across groups using univariate and multivariate statistics.

RESULTS

Rwandan students born before the end of the genocide and war in 1994 experienced higher psychotic and affective symptom load (p's < 0.001) with more functional impairment compared with younger Rwandans. 5.35% of older Rwandan students met threshold for clinical high-risk of psychosis by the WERCAP Screen compared with 3.19% of younger Rwandans (χ 2 = 5.36; p = 0.02). Symptom severity comparisons showed significant (p < 0.001) group effects between Rwandan and Kenyan secondary school students on affective and psychotic symptom domains with Rwandans having higher symptom burden compared with Kenyans. Rwandan female students also had higher rates of psychotic symptoms compared with their male counterparts - a unique finding not observed in the Kenyan sample.

CONCLUSIONS

These results suggest extreme conflict and disruption to country from genocide and war can influence the presence and severity of psychopathology in youth decades after initial traumatic events.

Post-traumatic stress disorder in internally displaced people of Colombia: An ecological study

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) has been described as one of the most frequently reported mental condition among refugees and internally displaced populations (IDPs). Despite this, few has been reported about it in Latin America, even in Colombia, the country with the highest number of IDPs in the in the world.

METHOD

This ecological study assessed incidence and differences of PTSD in general population and IDPs in Colombia and its departments (32) during 2009-2012. Epidemiological data was collected from the National Health Records System (RIPS), retrieving the ICD-10 code F43.1 in both populations. We estimated PTSD incidence rates on both populations (cases/100,000 pop), using reference population of the IDPs (SISDHES and the general population was taken from the (DANE). Incidence rates ratios were calculated comparing both populations.

RESULTS

In general population, 6619 cases of PTSD occurred (14.5 cases/100,000 pop, 95%CI 14.0-15.0) while 177 among IDPs (73.8 cases/100,000 pop, 95%CI 63.0-85.0). PTSD was 5.1 times higher among IDPs than in general population. Ranging from 1.6 (Tolima) to 15.8 (Quindío) (median: 4.4). In departments with higher incidence, also it was in IDPs (r² = 0.4899; p < 0.01).

CONCLUSION

This study evidenced a significantly higher PTSD incidence among IDPs, when compared with general population in the same territories. This has relevant implications for screening, diagnosis and management of PTSD among IDPs, especially in high incidence areas. More studies are required to improve the understanding of this condition among vulnerable populations, as well to provide better medical and psychological interventions and for the development of public policies in countries, such as Colombia, with IDPs.

Psychosocial wellbeing and physical health among Tamil schoolchildren in northern Sri Lanka

BACKGROUND

Mental disorders contribute to the global disease burden and have an increased prevalence among children in emergency settings. Good physical health is crucial for mental well-being, although physical health is multifactorial and the nature of this relationship is not fully understood. Using Sri Lanka as a case study, we assessed the baseline levels of, and the association between, mental health and physical health in Tamil school children.

METHODS

We conducted a cross sectional study of mental and physical health in 10 schools in Kilinochchi town in northern Sri Lanka. All Grade 8 children attending selected schools were eligible to participate in the study. Mental health was assessed using the Sri Lankan Index for Psychosocial Stress - Child Version. Physical health was assessed using Body Mass Index for age, height for age Z scores and the Multi-stage Fitness Test. Association between physical and mental health variables was assessed using scatterplots and correlation was assessed using Pearson's R.

RESULTS

There were 461 participants included in the study. Girls significantly outperformed boys in the MH testing t (459) = 2.201, p < 0.05. Boys had significantly lower average Body Mass Index for age and height for age Z scores than girls (BMI: t (459) = -4.74, p <0.001; Height: t (459) = -3.54, p < 0.001). When compared to global averages, both sexes underperformed in the Multi-Stage Fitness Test, and had a higher prevalence of thinness and stunting. We identified no meaningful association between the selected variables.

CONCLUSIONS

Our results do not support the supposition that the selected elements of physical health are related to mental health in post-conflict Sri Lanka. However, we identified a considerable physical health deficit in Tamil school children.

Integrating mental health into primary care for post-conflict populations: a pilot study

BACKGROUND

Mental health care in post-conflict settings is often not prioritized, despite its important public health role. There is a salient gap in integrating mental health into primary care, especially in post-conflict settings. In the post-conflict Northern province of Sri Lanka, a pilot study was conducted to explore the feasibility of integrating mental health into primary care through a mhGAP-based training intervention.

METHODS

Using the mhGAP training intervention modules, a 24 h training programme was held over 3 days for primary care practitioners serving post-conflict populations (including internally displaced people and returnees). mhGAP intervention guide and video material was used in the training. Pre/post knowledge increase was measured. A qualitative study was also nested within the training programme to explore views, attitudes and perceptions of primary care practitioners on integrating mental health into primary care in the region. In-depth interviews were conducted.

RESULTS

Twelve primary care practitioners participated. The average service duration of the group was 7.6 years. The mean pre- and post-test scores of the PCP group were 72.8 and 77.2 % respectively. All 12 took part in the qualitative component. Participants highlighted their experiences of conflict and displacement, discussed the health profiles/needs of post-conflict populations in the region and provided insight into mental health care and training needs at primary care level. Participants also provided feedback on the mhGAP-based training; the cultural and contextual relevance of training material and content.

CONCLUSION

This study was planned as a local demonstrative project to explore the feasibility of training primary care practitioners to promote the integration of mental health into primary care for post-conflict populations. To our knowledge, this is the first such attempt in Sri Lanka. Findings highlight the practical, operational and attitudinal barriers to integrate mental health into primary care, especially in resource-poor, post-conflict settings. Important feedback on mhGAP intervention guide, its implementation and training material was gained.

Mental health of displaced and returnee populations: Insight from the Sri Lankan post-conflict experience

The month of May 2015 marked the sixth year since the end of conflict in Sri Lanka. The cause of death, destruction and displacement, three decades of conflict has had a major impact on health, especially on mental health of those affected by forced displacement. Post-conflict regions of Sri Lanka has seen improvements in many areas, including resettlement of displaced populations and rebuilding of health-related infrastructure. However, substantial gaps exist around the management of health needs among returnee populations, especially in the area of psychosocial health. Long-term mental health and resilience trajectories of those affected by prolonged displacement and experiencing return migration during post-conflict periods remain important, yet critically understudied areas.