Political Violence and Mental Health in Nepal: War in Context,Structural Violence, and the Erasure of History Open Access

Kohrt, Brandon Alan (2009)

Permanent URL: https://etd.library.emory.edu/concern/etds/pc289j23x?locale=en
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Abstract

Abstract Political Violence and Mental Health in Nepal: War in Context, Structural Violence, and the Erasure of History By Brandon A. Kohrt The experience of war can have immediate and long-term consequences for the mental health of women, men, and children. Exposure to war and other forms of political violence typically occur against a backdrop of structural violence, which marginalizes populations and is a risk factor for poor mental health. The goal in this dissertation is to examine the effects of the People's War in Nepal on mental health taking into account the history of structural violence threats to mental health including caste-based and gender discrimination, poverty, and the exploitation and abuse of children. Methods drawn from anthropology, epidemiology, genetics, and endocrinology were employed to study two war-affected populations: civilian adults in a rural community and child soldiers. A three- component conceptual framework was developed to assess and model mental health: (1) War in context evaluates risk factors according to prewar, wartime, and postwar exposures; (2) Vulnerability refers to person-culture and gene-environment interactions which increase the risk of mental health problems; (3) Heterogeneity of outcomes demonstrates the need to examine a range of psychiatric and local categories of suffering as well as impaired functioning. Ethnopsychology-based models are especially important to address stigma in psychosocial interventions for war-affected children and adults. This conceptual framework fosters research and intervention that addresses war in the broader context of experience and prevents the erasure of history risked when exclusively investigating or treating war-related trauma.

Table of Contents

Table of Contents Publications and Contributions for Chapters ................................................................... viii Chapter 1: Introduction..................................................................................................... 12 Chapter 2: Navigating Diagnoses: Understanding Mind-Body Relations, Mental Health, and Stigma in Nepal...........................................................54 Chapter 3: Political Violence, Psychosocial Wellbeing and Mental Health: a Systematic Multi-disciplinary Review in Nepal...................................111 Chapter 4: Culture in Psychiatric Epidemiology: Using Ethnography and Multiple Mediator Models to Assess the Relationship of Caste with Depression and Anxiety in Nepal ..................................................................................152 Chapter 5: Exposure to political violence and impact on mental health: a prospective community follow-up study of the People's War in Nepal..........201 Chapter 6: Gene-environment interactions for FKBP5 polymorphisms and exposure to child maltreatment associated with depression, PTSD, and diurnal salivary cortisol levels in a community population in rural Nepal .........................242 Chapter 7: Children and Revolution: The Mental Health and Psychosocial Wellbeing of Child Soldiers in Nepal's Maoist Army............................304 Chapter 8: Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal....................346 Chapter 9: Traditional Healing and the Social Fabric: Implications for Psychosocial Interventions with Child Soldiers ......................................385 Chapter 10: Conclusion .....................................................456

Tables and Figures by Chapter Chapter 1: Introduction..................................................................................................... 1 Table 1-1a. Summary of studies of political violence and mental health conducted in law and middle-income countries in Africa...................8 Table 1-1b. Summary of studies of political violence and mental health conducted in law and middle-income countries in Asia.....................9 Table 1-1c. Summary of studies of political violence and mental health conducted in law and middle-income countries in Europe and Central America ....10 Figure 1-1. Percentage of persons with mental health problems (PTSD, Depression, Anxiety) by country. ......................................................11 Chapter 2: Navigating Diagnoses: Understanding Mind-Body Relations, Mental Health, and Stigma in Nepal..........................................................54 Table 2-1. Use of man (heart-mind) in everyday Nepali discourse...66 Table 2-2. Use of dimaag (brain-mind) in everyday Nepali discourse..................68 Figure 2-1. The framing of suffering by healers in Nepal through Mind-body relations. ........................................................................................77 Figure 2-2. Navigating Diagnoses: Pathways of helpseeking for psychological distress. .......................................................................................79 Chapter 3: Political Violence, Psychosocial Wellbeing and Mental Health: a Systematic Multi-disciplinary Review in Nepal...................................111

Table 3-1. Overview of Nepal's political history ....................................................... 117 Table 3-2a. Characteristics of included studies - State-sponsored violence .............. 120 Table 3-2b. Characteristics of included studies - Refugee crises............................... 121

Table 3-2c. Characteristics of included studies - Maoist Insurgency ........................ 123 Table 3-2d. Characteristics of included studies - Treatment findings........................ 128 Table 3-3. Overview of epidemiological findings ...................................................... 129 Chapter 4: Culture in Psychiatric Epidemiology: Using Ethnography and Multiple Mediator Models to Assess the Relationship of Caste with Depression and Anxiety in Nepal............................................................................................................................... 152 Figure 4-2. Illustration of multiple mediation design with 4 mediators and 2 controls. ..................................................................................................................................... 172 Table 4-1. Crude associations of caste, covariates and mental health outcomes (n=307)........................................................................................................................ 180 Table 4-2. Depression and anxiety by caste (n=307).................................................. 183 Table 4-3. Crude associations of number of stressful life events (SLEs) by category with caste and mental health outcomes (n=307)......................................................... 185 Table 4-4. Direct and indirect effects for Dalit/Nepali caste versus High Caste on depression and anxiety scales (n=307). ...................................................................... 187 Chapter 5: Exposure to political violence and impact on mental health: ....................... 201 a prospective community follow-up study of the People's War in Nepal ...................... 201 Figure 5-1. Jumla, Nepal. ........................................................................................... 210 Table 5-1. Baseline characteristics of participants (pre-conflict, year 2000) ............. 220 Table 5-2. Pre-conflict (year 2000) and post-conflict (year 2007) demographics (N=298)....................................................................................................................... 221 Table 5-3. Crude mental health and stressful life event exposure pre-conflict and postconflict (N=298) ......................................................................................................... 224

Figure 5-2. Beck Depression Inventory and Beck Anxiety Inventory mean scores by age group..................................................................................................................... 227 Figure 5-3: Stressful life events in prior 12 months (SLERS, stressful life events rating scale) and PTSD symptoms (PSCL, PTSD Symptom Checklist) mean scores by age group. .......................................................................................................................... 228 Table 5-4. Exposure to political violence and crude odds ratios for post-conflict (year 2007) mental disorders (N=298)................................................................................. 229 Table 5-5. Multivariate logistic regression for post-conflict mental health outcomes (N=298)....................................................................................................................... 230 Chapter 6: Gene-environment interactions for FKBP5 polymorphisms and exposure to child maltreatment associated with depression, PTSD, and diurnal salivary cortisol levels in a community population in rural Nepal ...................................................................... 242 Figure 6-1. Study site: Jumla, Nepal .......................................................................... 253 Figure 6-2. Recruitment.............................................................................................. 255 Table 6-1. Sample demographics................................................................................ 264 Table 6-2. FKBP5 SNPs frequencies by caste/ethnicity............................................. 266 Figure 6-3. Linkage disequilibrium R2 plots for FKBP5 by ethnicity/caste............... 268 Figure 6-4. P-values for FKBP5 SNP main effects and interaction with child maltreatment (CTQ score quartiles) for BDI total score, BDI somatic symptoms, BDI cognitive symptoms, and PTSD symptoms. ............................................................... 270 Table 6-3. General linear models (GLM) for 3 SNP risk haplotype (CAT) for depression with genotype main effect and gene-environment (childhood maltreatment) interaction, including all ethnic groups (N=680)........................................................ 271

Figure 6-5. Depression mean scores (error bars represent standard error of the mean) for BDI total score and BDI cognitive score by number of copies of FKBP5 three SNP risk haplotype by level of child maltreatment (CTQ quartiles). ................................. 273 Figure 6-6. Model including only Chhetri castes of depression mean scores (error bars represent standard error of the mean) for BDI total score and BDI cognitive score by number of copies of FKBP5 three SNP risk haplotype by level of child maltreatment (CTQ quartiles). .......................................................................................................... 274 Table 6-4. Pearson correlations by number of copies of FKBP5 three SNP risk haplotype..................................................................................................................... 275 Table 6-5: GLM of cortisol (natural log) at waking, plus 30 minutes, and evening in model with child maltreatment and FKBP5................................................................ 277 Figure 6-7: Diurnal salivary cortisol by child maltreatment and FKBP5 haplotype.. 278 Table 6-6: Association of child maltreatment and psychiatric symptom severity with log cortisol levels across the day among only persons with one or two copies of the FKBP5 3 SNP haplotype (n=62) ................................................................................ 279 Table 6-7: GLM of cortisol (natural log) at waking, plus 30 minutes, and evening in model with depression and FKBP5............................................................................. 281 Figure 6-8: Diurnal salivary cortisol by depression and FKBP5 haplotype............... 282 Figure 6-9: Diurnal salivary cortisol by cognitive depression and FKBP5 haplotype. ..................................................................................................................................... 283 Table 6-8: GLM of cortisol (natural log) at waking, plus 30 minutes, and evening in model with PTSD and FKBP5.................................................................................... 285 Figure 6-10: Diurnal salivary cortisol by PTSD and FKBP5 haplotype.................... 286

Chapter 7: Children and Revolution: The Mental Health and Psychosocial Wellbeing of Child Soldiers in Nepal's Maoist Army.......................................................................... 304 Figure 7-1. Social determinants of child conscription in armed groups..................... 321 Chapter 8: Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal............................................................................ 346 Table 8-1. Demography and Trauma Exposure of Former Child Soldiers and Matched Children Never Conscripted by Armed Groups.......................................................... 360 Table 8-2. Univariate and Multivariate Analyses of the Effects Child Soldier Status on Mental Health Outcomes Adjusted for Trauma Exposure and Other Covariates....... 363 Table 8-3. Characteristics of Child Soldiers............................................................... 367 Table 8-4. Predictors of Mental Health among Former Child Soldiers (N=141). ...... 369 Chapter 9: Traditional Healing and the Social Fabric: Implications for Psychosocial Interventions with Child Soldiers ................................................................................... 385 Figure 9-1. Rituals identified by community members for returned children............ 432 Chapter 10: Conclusion................................................................................................... 456 Figure 10-1. Framework for War in Context.............................................................. 462 Table 10-1. Traumatic Exposures among Civilian Children and Former Child soldiers ..................................................................................................................................... 498 Table 10-2. Exposure to political violence and crude odds ratios for post-conflict (year 2007) mental disorders (N=298)................................................................................. 498 Table 10-3. Role during association and impact on psychosocial wellbeing ............. 503 Table 10-4. Exposure to torture (n=810) .................................................................... 506 Figure 10-2. Torture and Mental Health...................................................................... 507

Table 10-5. Association of PTSD with type of trauma exposure ............................... 508 Table 10-6. Community views of returned girl soldiers and possibility for marriage 513 Table 10-7. Percentage of returned former child soldiers reporting difficulty from community members................................................................................................... 514 Figure 10-3. Framework for prewar, wartime, and postwar exposures on wellbeing 518 Figure 10-4. Change in depression and anxiety scores from pre- to postwar conditions based on risk groups.................................................................................................... 520 Table 10-8. Mental health by risk category in 2000. .................................................. 521 Figure 10-5. Depression among child soldiers and matched comparison children by gender and community religious composition............................................................ 525 Figure 10-6. Regression models for depression with interaction of sex and Hindu community. ................................................................................................................. 526 Figure 10-7. Discriminatory events experienced by child soldiers by gender and community composition.............................................................................................. 527 Figure 10-8. War in context framework for child soldier study................................. 530 Figure 10-9. Conflict mortality and prevalence rates of mental health problems. ..... 534 Figure 10-10. Model for post-conflict depression and anxiety. ................................. 535 Figure 10-11. War in context framework for Jumla study ......................................... 536 Figure 10-12. Psychological trauma in relation to a Nepali ethnopsychological framework................................................................................................................... 539 Table 10-9. Aspects of stigma, anthropological approaches, and interventions......... 552 Figure 10-13. Treatment points of entry based on ethnopsychological framework... 553

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