Ashley K. Hagaman

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BackgroundSince the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti’s Central Plateau.MethodsWe conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti’s Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively.ResultsThe mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5).ConclusionsA large proportion of Haiti’s Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

Depressive Trajectories and Risk of Disability and Mortality in Older Adults: Longitudinal Findings From the Health, Aging, and Body Composition Study

BACKGROUND Depression and disability are closely linked. Less is known regarding clinical and subclinical depressive symptoms over time and risk of disability and mortality. METHODS Responses to the Center for Epidemiologic Studies Short Depression scale (CES-D10) were assessed over a 4-year period in men (n = 1032) and women (n = 1070) aged 70-79 years initially free from disability. Depressive symptom trajectories were defined with group-based models. Disability (2 consecutive reports of severe difficulty walking one-quarter mile or climbing 10 steps) and mortality were determined for 9 subsequent years. Hazard ratios (HRs) were estimated using Cox proportional hazards adjusted for covariates. RESULTS Three trajectories were identified: persistently nondepressed (54% of men, 54% of women, mean baseline CES-D10: 1.16 and 1.46), mildly depressed and increasing (40% of men, 38% of women, mean baseline CES-D10: 3.60 and 4.35), and depressed and increasing (6% of men, 8% of women, mean baseline CES-D10: 7.44 and 9.61). Disability and mortality rates per 1,000 person years were 41.4 and 60.3 in men and 45.8 and 41.9 in women. Relative to nondepressed, men in the mildly depressed (HR = 1.45, 95% confidence interval [CI] 1.11-1.89) and depressed trajectories (HR = 2.12, 95% CI 1.33-3.38) had increased disability; women in the depressed trajectory had increased disability (HR = 2.02, 95% CI 1.37-2.96). Men in the mildly depressed (HR = 1.24, 95% CI 1.01-1.52) and depressed trajectories (HR = 1.63, 95% CI 1.10-2.41) had elevated mortality risk; women exhibited no mortality risk. CONCLUSIONS Trajectories of depressive symptoms without recovery may predict disability and mortality in apparently healthy older populations, thus underscoring the importance of monitoring depressive symptoms in geriatric care.

Determinants of Care Seeking for Mental Health Problems in Rural Haiti: Culture, Cost, or Competency

OBJECTIVE This study examined patterns, determinants, and costs of seeking care for mild to moderate psychiatric distress in order to determine optimal approaches for expanding mental health care in rural Haiti. METHODS A cross-sectional, zone-stratified household survey of 408 adults was conducted in Haitis Central Plateau. Multivariable logistic regression models were built to assess determinants of first-choice and lifetime health service use by provider type. RESULTS Thirty-two percent of respondents endorsed God as their first choice for care if suffering from mental distress, and 29% of respondents endorsed clinics and hospitals as their first choice. Forty-seven percent of respondents chose potential providers on the basis of anticipated efficacy. Suicidal individuals were 7.6 times (95% confidence interval [CI]=1.4-42.0) as likely to prefer community-based providers (herbal healer, church priest or pastor, or Vodou priest) over hospitals or clinics. Depression severity was associated with increased odds (adjusted odds ratio [AOR]=1.8, CI=1.5-2.3) of ever having been to an herbal healer. Having a household member with mental health problems was associated with increased odds of ever having been to church pastors or priests (AOR=5.8, CI=2.8-12.0) and decreased odds of ever having been to hospitals or clinics (AOR=.3, CI=.1-.8). Median actual service costs were US

How Many Interviews Are Enough to Identify Metathemes in Multisited and Cross-cultural Research? Another Perspective on Guest, Bunce, and Johnson’s (2006) Landmark Study

1 for hospitals or clinics,

Reflechi twòp—Thinking Too Much: Description of a Cultural Syndrome in Haiti’s Central Plateau

6 for herbal healers, and

An Investigation into Suicides Among Bhutanese Refugees Resettled in the United States Between 2008 and 2011

120 for Vodou priests. CONCLUSIONS Three out of four rural Haitians said they would seek community resources over clinical care if suffering from mental distress. Therefore, isolated clinical interventions may have limited impact because of less frequent use. Efforts to expand mental health care should consider differential provider costs when selecting community resources for task shifting.

The physiological cost of reproduction for rich and poor across 65 countries

There is much debate over the number of interviews needed to reach data saturation for themes and metathemes in qualitative research. The primary purpose of this study is to determine the number of interviews needed to reach data saturation for metathemes in multisited and cross-cultural research. The analysis is based on a cross-cultural study on water issues conducted with 132 respondents in four different sites. Analysis of the data yielded 240 site-specific themes and nine cross-cultural metathemes. We found that 16 or fewer interviews were enough to identify common themes from sites with relatively homogeneous groups. Yet our research reveals that larger sample sizes—ranging from 20 to 40 interviews—were needed to reach data saturation for metathemes that cut across all sites. Our findings may be helpful in estimating sample sizes for each site in multisited or cross-cultural studies in which metathematic comparisons are part of the research design.

Scale properties of the Kreyòl Distress Idioms (KDI) screener: association of an ethnographically-developed instrument with depression, anxiety, and sociocultural risk factors in rural Haiti

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti’s Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with “thinking too much” have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. “Thinking too much” is associated with 8 times greater odds of suicidal ideation. Untreated “thinking too much” is sometimes perceived to lead to psychosis. Recognizing and understanding “thinking too much” may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti’s Central Plateau.

Suicide surveillance and health systems in Nepal: a qualitative and social network analysis

An increase of Bhutanese refugee suicides were reported in the US between 2009 and 2012. This investigation examined these reported suicides in depth to gain a better understanding of factors associated with suicide within this population. The study employed 14 psychological autopsies to elicit underlying motivations and circumstances for self-inflicted death and to identify potential future avenues for prevention and intervention among refugee communities. Disappointment with current (un)employment, lack of resettlement services and social support, and frustrations with separation from family were believed to contribute to suicidal acts. Suicide within refugee populations may be connected with experiences of family withdrawal, integration difficulties, and perceived lack of care. It is important to assess the effectiveness of improving refugee services on the mental health of migrants. More research is needed in order to better understand, and respond to, suicide in resettled populations.

Task sharing in rural Haiti: Qualitative assessment of a brief, structured training with and without apprenticeship supervision for community health workers

One of the fundamental tradeoffs posited in life history theory is between storing energy for future reproduction versus spending that energy on current reproduction. However, past studies have shown variable and sometimes contradictory effects of reproduction on energy stores among women.