Paul Bolton

Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence

BACKGROUND Survivors of sexual violence have high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). Although treatment for symptoms related to sexual violence has been shown to be effective in high-income countries, evidence is lacking in low-income, conflict-affected countries. METHODS In this trial in the Democratic Republic of Congo, we randomly assigned 16 villages to provide cognitive processing therapy (1 individual session and 11 group sessions) or individual support to female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms. One village was excluded owing to concern about the competency of the psychosocial assistant, resulting in 7 villages that provided therapy (157 women) and 8 villages that provided individual support (248 women). Assessments of combined depression and anxiety symptoms (average score on the Hopkins Symptom Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), PTSD symptoms (average score on the PTSD Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), and functional impairment (average score across 20 tasks [range, 0 to 4, with higher scores indicating greater impairment]) were performed at baseline, at the end of treatment, and 6 months after treatment ended. RESULTS A total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments. Mean scores for combined depression and anxiety improved in the individual-support group (2.2 at baseline, 1.7 at the end of treatment, and 1.5 at 6 months after treatment), but improvements were significantly greater in the therapy group (2.0 at baseline, 0.8 at the end of treatment, and 0.7 at 6 months after treatment) (P<0.001 for all comparisons). Similar patterns were observed for PTSD and functional impairment. At 6 months after treatment, 9% of participants in the therapy group and 42% of participants in the individual-support group met criteria for probable depression or anxiety (P<0.001), with similar results for PTSD. CONCLUSIONS In this study of sexual-violence survivors in a low-income, conflict-affected country, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms and improved functioning. (Funded by the U.S. Agency for International Development Victims of Torture Fund and the World Bank; ClinicalTrials.gov number, NCT01385163.).

Assessment of depression prevalence in rural Uganda using symptom and function criteria

Abstract.Background:We sought to assess the prevalence of major depression in a region of sub-Saharan Africa severely affected by HIV, using symptom and functional criteria as measured with locally validated instruments.Method:Six hundred homes in the Masaka and Rakai districts of southwest Uganda were selected by weighted systematic random sampling. A locally validated version of the depression section of the Hopkins Symptom Check List (DHSCL) and a community-generated index of functional impairment were used to interview 587 respondents.Results:Of respondents,21% were diagnosed with depression using three of the five DSM-IV criteria (including function impairment) compared with 24.4 % using symptom criteria alone. Increased age and lower educational levels are associated with a greater risk for depression; however, a gender effect was not detected.Conclusions:Most community-based assessments of depression in sub-Saharan Africa based on the DSM-IV have used symptom criteria only.We found that expanding criteria to more closely match the complete DSM-IV is feasible, thereby making more accurate assessments of prevalence possible. This approach suggests that major depression and associated functional impairment are a substantial problem in this population.

Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study

Abstract Sub-Saharan Africa contains over 60% of the worlds HIV infections and Zambia is among the most severely affected countries in the region. As antiretroviral programs have been rapidly expanding, the long-term success of these programs depends on a good understanding of the behavioral determinants of acceptance and adherence to antiretroviral therapy (ART). The study used qualitative methods to gain local insight into potentially important factors affecting HIV-infected womens decision to accept or continue with ART. Some of the barriers identified by this study are consistent with factors cited in the existing adherence literature from both developed and developing nations such as side effects, hunger and stigma; other factors have not been previously reported. One major theme was unfamiliarity with the implications of having a chronic, potentially deadly disease. Other emerging themes from this study include the complicated effect of ART on interpersonal relationship, particularly between husbands and wives, the presence of depression and hopelessness, and lack of accurate information. The results suggest that the reasons for non-uptake of treatment include issues related to local cultural frameworks (e.g., illness ideology), mental and behavioral health (e.g., depression and/or interpersonal challenges), stigma, and motivating factors (e.g., values of church or marriage) of different cultures that affect the ability and willingness to take life-saving medicine for a long period of time. Qualitative studies are critical to better understand why ART eligible individuals are choosing not to initiate or continue treatment to achieve needed adherence levels.

Prevalence of depression in rural Rwanda based on symptom and functional criteria.

The authors’ objective was to estimate the prevalence of major depressive disorder among Rwandans 5 years after the 1994 genocidal civil war. They interviewed a community-based random sample of adults in a rural part of Rwanda using the Hopkins Symptom Checklist and a locally developed functional impairment instrument. The authors estimated current rates of major depression using an algorithm based on the DSM-IV symptom criteria (A), distress/functional impairment criteria (C), and bereavement exclusionary criteria (E). They also examined the degree to which depressive symptoms compromise social and occupational functioning. Three hundred sixty-eight adults were interviewed, of whom 15.5% met Criteria A, C, and E for current major depression. Depressive symptoms were strongly associated with functional impairment in most major roles for men and women. The authors conclude that a significant part of this population has seriously disabling depression. Work on appropriate, feasible, safe, and effective mental health interventions should be a priority for this population.

A Qualitative Study of Mental Health Problems among Children Displaced by War in Northern Uganda

While multiple studies have found that children affected by war are at increased risk for a range of mental health problems, little research has investigated how mental health problems are perceived locally. In this study we used a previously developed rapid ethnographic assessment method to explore local perceptions of mental health problems among children and adults from the Acholi ethnic group displaced by the war in northern Uganda. We conducted 45 free list interviews and 57 key informant interviews. The rapid assessment approach appears to have worked well for interviewing caretakers and children aged 10—17 years. We describe several locally defined syndromes: two tam/par/kumu (depression and dysthymia-like syndromes), ma lwor (a mixed anxiety and depression-like syndrome), and a category of conduct problems referred to as kwo maraco/gin lugero. The descriptions of these local syndromes were similar to western mood, anxiety and conduct disorders, but included culturespecific elements.

Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers

BackgroundRecent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC).Model and case presentationsThis paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors.EvaluationWe review the challenges experienced with this model, and propose some possible solutions.DiscussionWe describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature.ConclusionIn our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions.

Deaths among humanitarian workers

The nature of humanitarian relief has changed dramatically in the past decade as conflicts have ceased being wars between states and are now largely internal conflict taking place amid the anarchy of weakened or collapsed states.1 Increasingly, civilians and those who try to protect and assist them are seen as legitimate targets for extortion, harassment, rape, and brutality.2 Providing assistance while protecting the providers is the dilemma facing all international aid organisations. 3 4 To gain a better understanding of deaths in this group, we analysed 382 deaths in humanitarian workers between 1985 and 1998. Most humanitarian organisations believe that the number of deaths among relief workers has been increasing.5 Although data exist for deaths among development workers, Peace Corps volunteers, and other expatriates, there have been no data on deaths among humanitarian workers.6–9 #### Summary points Wars between states have been largely replaced by internal conflict and anarchy, which have put the lives of civilians and humanitarian workers at ever increasing risk Between 1985 and 1998 nearly a half of deaths traced were in workers from UN programmes, and a quarter were in UN peacekeepers Most deaths were due to intentional violence (guns or other weapons), many associated with banditry One third of deaths occurred in the first 90 days of service, with 17% dying within the first 30 days; the timing of death was unrelated to previous field experience The number of deaths peaked with the Rwanda crisis in 1994 and has been decreasing for all groups except for non-governmental organisations, where it continues to increase We collected information from the records of aid agencies and organisations. We included any death between 1985 and 1998 occurring in workers in the field or as a result of them having worked in the field during emergency or …

Editorial: Treating depression in the developing world

Despite the contention by the WHO (2001a) that depression is a major cause of disability in the world, this illness receives little programmatic and research attention in developing countries. There are several reasons for this. First, it is believed in many circles that depression is a ‘Western’ diagnostic entity with limited public health relevance in other cultures. This belief persists despite evidence of numerous studies across the developing world which have shown that depression is highly prevalent and associated with disability and poverty (WHO 2001a). Qualitative studies have confirmed the clinical validity of the illness construct of depression in non-Western cultures (Bolton 2001; Rodrigues et al. 2003; Wilk & Bolton 2002). Secondly, there is a view that depression is not important because the illness does not directly contribute to mortality. Thirdly, it is believed that effective and affordable treatment for depression is not possible in poor countries. This relegates depression to low priority when it comes to identifying and implementing effective and feasible interventions for the most pressing health problems in poor countries. Low-income countries have extremely meagre resources for mental illness and little progress has been made in improving treatment modalities. Although most have an essential drugs policy, approximately 20% do not even have the most commonly prescribed drugs for depression (WHO 2001b). In approximately half of all countries, and in most developing countries, there is no more than one psychiatrist and one psychiatric nurse per 100 000 population; the numbers of psychologists and social workers working in the field of mental health are even smaller. As a result of this scarcity of mental health resources, the overwhelming majority of persons with depression have little chance of specialist treatment. Studies in primary-care settings typically show that the vast majority of patients do not receive evidence-based treatment for depression (Linden et al. 1999). Until recently, all evidence for effective treatment of depression was derived from randomized-controlled trials in developed countries, and the cross-national applicability of these studies had been questioned on a number of grounds (Patel 2000). These include cultural factors such as the local acceptability of specific interventions; health system factors such as the availability of human resources to implement interventions; costs and availability of medications; and individual patient factors such as pharmacodynamic variations between populations – all of which could influence the cross-cultural validity of treatment evidence. Thus we know that millions of people suffer with depression and that there is a strong association with poverty and disability, but there was little research on what developing countries with meagre mental health resources and low awareness could do for depressed patients. Last year, three randomized-controlled trials were published on the efficacy and cost-effectiveness of the treatment of depression in India, Uganda and Chile (Araya et al. 2003; Bolton et al. 2003; Patel et al. 2003). These trials shared a number of features, including preparatory work in which measures for depression were translated and validated for the local culture; and epidemiological studies undertaken to estimate prevalence and risk factors (Araya et al. 1994; Patel et al. 1998; Bolton & Wilk 2004). All studies targeted poor populations. The Indian and Chilean trials were located in low-income urban primary or general health care settings while the Ugandan trial was in a poor rural community. All tested treatment options were intended to be feasible and affordable to the populations being studied. So, what worked? All three trials had a psychological intervention; however, only the two trials which employed a group-based intervention found that it was efficacious. The individual psychological intervention used in India was no better than placebo; this lack of efficacy was, in all probability, due to the culturally unacceptable nature of a purely ‘talking’ intervention by a professional therapist. However, group therapy that emphasizes support and sharing between members of the same community was Tropical Medicine and International Health

Local perceptions of the mental health effects of the Uganda acquired immunodeficiency syndrome epidemic

Despite much attention in developed countries, little is known about the relationship between mental health problems and the human immunodeficiency virus (HIV) in Africa. The objectives of the current study were a) to investigate how people in an African community severely affected by HIV view the mental health effects of the epidemic and b) to use these data to investigate the local construct validity of the Western concepts of depression and posttraumatic stress disorder. Ethnographic methods—free listing and key-informant interviews—were used among participants from the Rakai and Masaka districts of southwest Uganda. Participants described two independent depression-like syndromes (Yo’kwekyawa and Okwekubaziga) resulting from the HIV epidemic. No syndromes similar to posttraumatic stress disorder were detected. We conclude that local people recognize depression syndromes and consider them pertinent consequences of the HIV epidemic.

Violence and abuse among HIV-infected women and their children in Zambia: a qualitative study.

HIV and violence are two major public health problems increasingly shown to be connected and relevant to international mental health issues and HIV-related services. Qualitative research is important due to the dearth of literature on this association in developing countries, cultural influences on mental health syndromes and presentations, and the sensitive nature of the topic. The study presented in this paper sought to investigate the mental health issues of an HIV-affected population of women and children in Lusaka, Zambia, through a systematic qualitative study. Two qualitative methods resulted in the identification of three major problems for women: domestic violence (DV), depression-like syndrome, and alcohol abuse; and children: defilement, DV, and behavior problems. DV and sexual abuse were found to be closely linked to HIV and alcohol abuse. This study shows the local perspective of the overlap between violence and HIV. Results are discussed in relation to the need for violence and abuse to be addressed as HIV services are implemented in sub-Saharan Africa.