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Pullen SJ, Herman AR, Lange BC, Christian-Brathwaite N, Ulloa M, Kempeh MP, Karnga DG, Fallah MP, Menyongai J, Harris B, Alonso Y, Henderson DC, Borba CP. Towards a better understanding of attitudes and beliefs held by traditional healers and recipients of traditional medicine concerning mental health conditions in post-conflict Liberia: a qualitative investigation. Afr Health Sci 2021; 21:1396-1409. [PMID: 35222605 PMCID: PMC8843300 DOI: 10.4314/ahs.v21i3.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background A better understanding of attitudes and beliefs held by traditional healers and utilizers of traditional medicine concerning mental health conditions in Liberia is important as Liberia seeks to improve its delivery of mental healthcare in the context of scarce resources and recovery from civil war. Methods A qualitative research design was used to collect data from 24 Liberian traditional healers, and 11 utilizers of Liberian traditional medicine. Participants were queried about mental health problems in Liberia, treatments, and attitudes towards modern healthcare. Qualitative data were probed and aggregated using content analysis. Results Mental health problems described by study participants included: Open Mole, African Science, Epilepsy, Depression and Mental Illness (trauma/substance use). Mental health problems were often associated with socioeconomic distress, and participants described their attitudes and beliefs concerning mental healthcare, traditional medicine, and modern healthcare. Conclusion Traditional medicine is an important part of mental healthcare in Africa. Mental illness, social factors, and healthcare access were important problems in Liberia. Mental health problems blended local cultural beliefs with Westernized nosology and social factors. Traditional healer's attitudes towards Western medicine reflected ambivalence. There is a desire for collaboration with ‘modern’ health care providers, but this will require reciprocal trust-building.
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Affiliation(s)
- Samuel J Pullen
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, Division of Child and Family Mental Health and Community Psychiatry, Durham, NC.,Johns Hopkins Bloomberg School of Public Health, Baltimore
| | | | - Brittany Cl Lange
- University of Oxford - Department of Social Policy and Intervention, Oxford, England
| | | | - Melissa Ulloa
- New York University Steinhardt School of Culture, Education, and Human Development, 82 Washington Square E, New York, NY 10003
| | - Michael P Kempeh
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia, College of Medicine University of Liberia, Monrovia, Liberia, West Africa
| | - Dyujay G Karnga
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia, College of Medicine University of Liberia, Monrovia, Liberia, West Africa
| | - Mosoka P Fallah
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia, College of Medicine University of Liberia, Monrovia, Liberia, West Africa.,National Public Health Institute of Liberia, Monrovia, Liberia
| | | | - Benjamin Harris
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia, College of Medicine University of Liberia, Monrovia, Liberia, West Africa
| | - Yadira Alonso
- Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA
| | - David C Henderson
- Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA
| | - Christina Pc Borba
- Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA
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Hook K, Ando K, Ghebrehiwet S, Harris B, Ojediran B, Syeda H, Henderson D, Borba C. Current state of the literature on mental health in Liberia: A systematic review. S Afr J Psychiatr 2020; 26:1502. [PMID: 33240551 PMCID: PMC7670006 DOI: 10.4102/sajpsychiatry.v26i0.1502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background The Republic of Liberia recently experienced several events that resulted in wide-ranging societal impacts, including long-term civil war and an outbreak of Ebola. These types of events are linked to higher prevalence of mental disorders and psychosocial distress. As a result, it is likely that there is an increased prevalence of mental health disorders in the population. Aim To assess and review the recent mental health literature in order to provide insight into existing mental health needs and effective or recommended interventions in post-conflict Liberia. Setting Articles included in this study enrolled Liberians living in Liberia. Methods A search of four databases was conducted for studies of any type that assessed mental health in Liberia between 01 January 2003 and 27 March 2019. After reviewing 363 articles, 21 articles were included in the final analysis. Articles were coded to identify common themes and needs. Results The majority of studies used qualitative designs and were conducted in Monrovia, the capital city of Liberia. Common topics included adolescent mental health, intervention and assessment and post-conflict impacts. One article focused on mental health impacts after recovery from Ebola. Conclusion Overall, there is a dearth of mental health literature that focuses on Liberia. This suggests ample opportunity for researchers to investigate mental health needs amongst the Liberian population and effective psychiatric interventions. Existing recommendations often focus on addressing adolescent health needs, including substance use practices. Opportunities for future research particularly related to needs of adult populations and to mental health impacts of Ebola, abound.
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Affiliation(s)
- Kimberly Hook
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States of America.,Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA,United States of America
| | - Kanako Ando
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America
| | - Senait Ghebrehiwet
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America
| | - Benjamin Harris
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Babawale Ojediran
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Haniya Syeda
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America
| | - David Henderson
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States of America.,Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America
| | - Christina Borba
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States of America.,Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America
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Decosimo CA, Hanson J, Quinn M, Badu P, Smith EG. Playing to live: outcome evaluation of a community-based psychosocial expressive arts program for children during the Liberian Ebola epidemic. Glob Ment Health (Camb) 2019; 6:e3. [PMID: 31143464 PMCID: PMC6521133 DOI: 10.1017/gmh.2019.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This paper reviews the efficacy of a community psychosocial arts program focused on building mental health capacity within post-Ebola Liberia. The aim of this paper was to evaluate the outcome effects of two groups using pre- and post-treatment data. We hypothesized that there would be a difference in symptoms pre- and post-treatment, and the longer program would yield more significant results. METHODS There was a total of 870 child participants. Of 40 sites, 24 were selected for a 5-month treatment (TG1) while the remaining 16 sites received 3 months of treatment (TG2). Paired t tests and a mixed-model analysis of variance (ANOVA) were used to analyse pre- and post-psychological stress symptoms (PSS) for samples from both groups. RESULTS Separately, treatment group 1 (TG1) and treatment group 2's (TG2) paired t test yielded significant results (p < 0.001) for the decrease of PSS. The mixed-model ANOVA found that there were significant differences in total pre- and post-test PSS and a significant difference in PSS means over time. CONCLUSIONS Results indicated that there was a statistically significant decrease in reported symptoms in both treatment groups pre- to post-intervention and a significant difference in total symptoms over time. However, the findings do not indicate that the longer programming was statistically different compared to the shorter programming. The study presented had gaps in data, largely due to limits in research during the crisis. However, this paper provides a unique case study for challenges that can be faced for project evaluation in emergency settings.
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Affiliation(s)
- C. A Decosimo
- Playing to Live, East Tennessee State University, Johnson City, TN, USA
| | - J. Hanson
- University of Pittsburg, Pittsburgh, PA, USA
| | - M. Quinn
- East Tennessee State University, Johnson City, TN, USA
| | - P. Badu
- Playing to Live, Renewed Energy Serving Humanity, Paynesville, Liberia
| | - E. G. Smith
- Renewed Energy Serving Humanity, Monrovia, Liberia
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Abstract
Between 1989 and 2003, Liberia experienced a brutal civil war characterized by ethnic killings, sexual violence and the use of child soldiers. Five years after the war ended, half the population of Liberia was under 18 years old. Understanding the needs of these youth is thus essential to the recovery of the nation. This study focuses on the narratives of two female adolescents, selected from 75 in-depth individual interviews with post-conflict Liberian youth conducted in 2012. A narrative analysis approach was employed to examine each interview for multiple layers of meaning. The aim of the study was to elucidate factors that may enable post-conflict youth to reclaim a sense of agency and return to normal developmental tasks. The study explores the ways in which these youth navigate complicated power dynamics in the post-conflict setting and how gender impacts their experiences of their own agency and capability. The dynamics between the participants and the interviewer are explored to further illustrate how power dynamics manifest. These narratives support the involvement of youth in projects that help others as an avenue for promoting agency and resilience for themselves.
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Levey EJ, Oppenheim CE, Lange BCL, Plasky NS, Harris BL, Lekpeh GG, Kekulah I, Henderson DC, Borba CPC. A qualitative analysis of parental loss and family separation among youth in post-conflict Liberia. VULNERABLE CHILDREN AND YOUTH STUDIES 2017; 12:1-16. [PMID: 28163770 PMCID: PMC5214285 DOI: 10.1080/17450128.2016.1262978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/09/2016] [Indexed: 06/06/2023]
Abstract
Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.
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Affiliation(s)
- Elizabeth J. Levey
- Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, University of Illinois College of Medicine, Chicago, IL, USA
| | | | | | - Naomi S. Plasky
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Benjamin L. Harris
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - G. Gondah Lekpeh
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Isaac Kekulah
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - David C. Henderson
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Christina P. C. Borba
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
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Levey EJ, Oppenheim CE, Lange BCL, Plasky NS, Harris BL, Lekpeh GG, Kekulah I, Henderson DC, Borba CPC. A qualitative analysis of factors impacting resilience among youth in post-conflict Liberia. Child Adolesc Psychiatry Ment Health 2016; 10:26. [PMID: 27525038 PMCID: PMC4983000 DOI: 10.1186/s13034-016-0114-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/02/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2008, 5 years after the Liberian civil war ended, there were an estimated 340,000 orphans in Liberia, 18 % of the total child population of the country. Given that children make up half the population and that these children experienced significant trauma and loss both through direct exposure to the war and then to the Ebola epidemic, and indirectly as a result of the trauma experienced by their parents, the recovery of these children is essential to the recovery of the nation as a whole. The goal of this research was to identify factors contributing to resilience among youth in post-conflict Liberia. Resilience was defined as evidence of adaptive functioning and psychological health. METHODS Seventy-five young people (age 13-18) in the capital city of Monrovia, Liberia were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. RESULTS Forty-six of the participants were attending school, and 29 were not enrolled in school. Youth enrolled in school demonstrated greater adaptive functioning. This was particularly true for boys in any school setting and girls attending private school. Youth not attending school were more likely to have lost family members or become estranged from them, and many were also engaging in substance use. Emotion regulation, cognitive flexibility, agency, social intelligence and, in some cases, meaning-making were found in participants who showed resilient outcomes. CONCLUSIONS Caregiver relationships mediate the development of psychological capacities that impact resilience. These findings suggest that youth who have lost a caregiver, many of whom are not attending school, are experiencing a significant ongoing burden in terms of their daily functioning and psychological health in the post-war period and should be the focus of further study and intervention targeting substance use and community reintegration. Trial registration Partners Healthcare IRB Protocol# 2012P000367.
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Affiliation(s)
- Elizabeth J. Levey
- The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, 5 Longfellow Place, Boston, MA 02114 USA ,Harvard Medical School, 25 Shattuck St., Boston, MA 02115 USA ,University of Illinois College of Medicine, 1853 West Polk St, Chicago, IL 60612 USA
| | - Claire E. Oppenheim
- Department of Psychiatry, Boston Medical Center, 840 Harrison Ave, Boston, MA 02118 USA
| | - Brittany C. L. Lange
- Department of Social Policy and Intervention, University of Oxford, Barnett House, 32-37 Wellington Square, Oxford, UK
| | - Naomi S. Plasky
- Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St, Baltimore, MD 21205 USA
| | - Benjamin L. Harris
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - G. Gondah Lekpeh
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Isaac Kekulah
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - David C. Henderson
- Department of Psychiatry, Boston Medical Center, 840 Harrison Ave, Boston, MA 02118 USA ,Boston University School of Medicine, 72 East Concord St, Boston, MA 02118 USA
| | - Christina P. C. Borba
- Department of Psychiatry, Boston Medical Center, 840 Harrison Ave, Boston, MA 02118 USA ,Boston University School of Medicine, 72 East Concord St, Boston, MA 02118 USA
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Pullen SJ, Petruzzi L, Lange BCL, Parnarouskis L, Dominguez S, Harris B, Quiterio N, Durham MP, Lekpeh G, Manobah B, Slopadoe SP, Diandy VC, Payne AJ, Henderson DC, Borba CPC. A Qualitative Analysis of Substance Use among Liberian Youth: Understanding Behaviors, Consequences, and Protective Factors Involving School Youth and the School Milieu. INTERNATIONAL JOURNAL OF MENTAL HEALTH & PSYCHIATRY 2016; 2:116. [PMID: 27158680 PMCID: PMC4857765 DOI: 10.4172/2471-4372.1000116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Substance use is a significant and common problem among school-aged youths throughout Africa. Like other countries on this continent, the West-African nation of Liberia is recovering from civil war. A well-educated population of young people is critical to the recovery efforts and long-term success of Liberia. Substance use by school-aged youths has important public health consequences that could undermine Liberia's post-conflict recovery efforts. We wanted to better understand the culturally significant themes and subthemes related to substance use among youths attending public schools in Monrovia, Liberia. METHODS A qualitative research design was used to collect data from 72 students attending public school in Monrovia, Liberia. Nine focus groups of 6-8 students from three public schools were facilitated using a semi-structured format to guide discussions on substance use. Student narratives were translated and re-occurring themes and subthemes were coded and analyzed. RESULTS Four emergent themes described in this study were: Behaviors associated with substance useConsequences associated with individual useConsequences of substance use that affected the school milieuSchool-related factors that were protective from substance use.Subthemes associated with substance use included concealment of substances, intoxication and disruption of the classroom environment, expulsion from school, school drop-out, and school as protective against substance use. CONCLUSION Liberian school-aged youths described important themes and subthemes associated with substance use occurring within the school milieu. These data have germane public health ramifications, and could help inform larger epidemiologic study methods and public health interventions for Liberia and countries with similar profiles.
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Affiliation(s)
- Samuel J Pullen
- St. Luke’s Health System Department of Psychiatry and Behavioral Health, Boise ID, USA
| | - Liana Petruzzi
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- University of Texas at Austin School of Social Work, Austin, TX, USA
| | - Brittany CL Lange
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Lindsey Parnarouskis
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Silvia Dominguez
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston MA, USA
| | - Benjamin Harris
- AM Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | | | - Michelle P Durham
- Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Gondah Lekpeh
- AM Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Burgess Manobah
- AM Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | | | | | - Arthur J Payne
- Christ Jubilee International Ministries, Lowell, MA, USA
| | - David C Henderson
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston MA, USA
- Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Christina PC Borba
- Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston MA, USA
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Borba CPC, Ng LC, Stevenson A, Vesga-Lopez O, Harris BL, Parnarouskis L, Gray DA, Carney JR, Domínguez S, Wang EKS, Boxill R, Song SJ, Henderson DC. A mental health needs assessment of children and adolescents in post-conflict Liberia: results from a quantitative key-informant survey. ACTA ACUST UNITED AC 2015; 9:56-70. [PMID: 26807147 PMCID: PMC4706023 DOI: 10.1080/17542863.2015.1106569] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
Abstract
Between 1989 and 2004, Liberia experienced a devastating civil war that resulted in widespread trauma with almost no mental health infrastructure to help citizens cope. In 2009, the Liberian Ministry of Health and Social Welfare collaborated with researchers from Massachusetts General Hospital to conduct a rapid needs assessment survey in Liberia with local key informants (n = 171) to examine the impact of war and post-war events on emotional and behavioral problems of, functional limitations of, and appropriate treatment settings for Liberian youth aged 5–22. War exposure and post-conflict sexual violence, poverty, infectious disease and parental death negatively impacted youth mental health. Key informants perceived that youth displayed internalizing and externalizing symptoms and mental health-related functional impairment at home, school, work and in relationships. Medical clinics were identified as the most appropriate setting for mental health services. Youth in Liberia continue to endure the harsh social, economic and material conditions of everyday life in a protracted post-conflict state, and have significant mental health needs. Their observed functional impairment due to mental health issues further limited their access to protective factors such as education, employment and positive social relationships. Results from this study informed Liberia's first post-conflict mental health policy.
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Affiliation(s)
- Christina P C Borba
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA; Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Lauren C Ng
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA; Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Anne Stevenson
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Oriana Vesga-Lopez
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA; Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Benjamin L Harris
- AM Dogliotti College of Medicine, University of Liberia , Monrovia , Liberia
| | - Lindsey Parnarouskis
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Deborah A Gray
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Julia R Carney
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Silvia Domínguez
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Edward K S Wang
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA; Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Ryan Boxill
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - Suzan J Song
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital , Boston , USA
| | - David C Henderson
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA; Department of Psychiatry, Harvard Medical School, Boston, USA; Department of Epidemiology, Harvard School of Public Health, Boston, USA
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