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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