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Studies in high-income countries have shown an association between heatwaves and hospital admissions for mental disorders. It is unknown whether such associations exist in subtropical nations like Vietnam. The study aim was to investigate whether hospital admissions for mental disorders may be triggered, or exacerbated, by heat exposure and heatwaves, in a low- and middle-income country, Vietnam. For this, we used data from the Hanoi Mental Hospital over five years (2008-2012) to estimate the effect of heatwaves on admissions for mental disorders. A zero-inflated negative binomial regression model accounting for seasonality, time trend, days of week, and mean humidity was used to analyse the relationship. Heatwave events were mainly studied as periods of three or seven consecutive days above the threshold of 35°C daily maximum temperature (90th percentile). The study result showed heatwaves increased the risk for admission in the whole group of mental disorders (F00-79) for more persistent heatwaves of at least 3 days when compared with non-heatwave periods. The relative risks were estimated at 1.04 (0.95-1.13), 1.15 (1.005-1.31), and 1.36 (1-1.90) for a one-, three- and seven-day heatwave, respectively. Admissions for mental disorders increased among men, residents in rural communities, and the elderly population during heatwaves. The groups of organic mental disorders, including symptomatic illnesses (F0-9) and mental retardation (F70-79), had increased admissions during heatwaves. The findings are novel in their focus on heatwave impact on mental diseases in a population habituating in a subtropical low- and middle-income country characterized by rapid epidemiological transitions and environmental changes.

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BACKGROUND: Traumatic events experienced by parents who have survived genocide influence mental health among their offspring. This study aims at exploring how the communication of traumatic events between Khmer Rouge survivors and their offspring was perceived by both generations. METHODS: Qualitative interviews were performed with six Khmer Rouge survivors and with six young people representing the second generation and were analysed using a content analysis approach. DISCUSSION: Parents felt that informing their children was important to instill gratitude for living a better life and to empower them. Among children, this was met with empathy but sometimes also disbelief and at times they blamed their parents for being too submissive. CONCLUSION: The study discloses the complexity, pros and cons of intergenerational sharing of trauma.

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BACKGROUND: Young people in low and middle income countries (LMICs) in societal transitions with rapidly changing norms face an increased risk of suicide. This study explores how young people in Cambodia understand the impact on suicidal behaviour from societal attitudes, media and religion. MATERIAL: Focus group discussions were held with school students from a suburban area. Thematic analysis was used to interpret the data. DISCUSSION: Participants perceived the prevailing suicide-stigmatizing societal attitudes, the double-edged media and suicide-ambiguity in Buddhist religion as challenging. Globalization was recognized as contradicting with traditional Cambodian norms and values. CONCLUSION: Suicide prevention programmes should take into consideration the complex picture of suicide that young people are exposed to.

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BACKGROUND: Deliberate self-harm (DSH) is a growing problem among young people and is a major risk factor for suicide. Young adults experiencing mental distress and suicidal ideation are reluctant to seek help, requiring new strategies to reach this group. AIMS: The present study explored young people's views of professional care before first contact for DSH, and factors that influenced the establishing of contact. METHOD: Interviews with 10 young individuals, shortly after they had harmed themselves, were analyzed using qualitative content analysis. RESULTS: The participants emphasized the importance of receiving more knowledge on where to turn, having different help-seeking options, and receiving immediate help. Family and friends were vital for support and making health care contact. The quality of the professional contact was stressed. Several reasons for not communicating distress were mentioned. Two themes were identified: "A need for a more flexible, available and varied health care" and "A struggle to be independent and yet being in need of reliable support." CONCLUSION: These findings suggest that easy and direct access to professional help is a decisive factor for young people experiencing psychological problems and that health services must find new ways of communicating information on seeking mental health help.

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BACKGROUND: Deliberate self-harm (DSH) is increasingly common among young people. At the same time, treatment and support after DSH are often hampered by low compliance. AIM: To explore young people's perceptions of care and support during a 6-month period following their first contact for DSH. METHODS: We conducted nine semistructured interviews with young people aged 16-24 years 6 months after their first contact for DSH. The interviews were analyzed using qualitative content analysis. RESULTS: Three main themes were extracted from the interviews. "Am I really in good hands?" describes whether the participants felt they were being listened to and taken seriously and whether they could rely on the competence of the professionals and the appropriateness of treatment, including keeping agreements and communication with other relevant agencies. "Help should match life circumstances" comprises how basic practicalities such as travel possibilities affect treatment and concomitant assistance in everyday living. Financial matters and jobseeking were perceived as necessary for optimal treatment and well-being. "Making yourself better" includes participants' efforts to manage on their own, through realizing their own responsibility to be engaged and actively take part in treatment planning. CONCLUSION: Flexibility and responsiveness to young people's own views and specific needs in treatment arrangements are of crucial importance. The significance of basic practical help cannot be underestimated and should not be overlooked.

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Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly 'trauma focused', a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will.

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BACKGROUND: Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far. METHODS: A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome. RESULT: About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia. CONCLUSION: This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.

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BACKGROUND: Mental health problems among young peoples are a growing public health issue around the world. In low- income countries health systems are characterized by lack of facilities, human resources and primary health care is rarely an integrated part of overall health care services. This study aims at exploring how primary health care professionals in Nicaragua perceive young people's mental health problems, suicidal problems and help-seeking behaviour. METHODS: Twelve in-depth interviews were conducted with nurses and doctors working in primary health care services in León, Nicaragua. A qualitative research design was applied. Data was analysed using thematic analysis approach. RESULTS: This study revealed that doctors and nurses were reluctant to deal with young people presenting with suicidal problems at the primary health care. This was more likely to stem from feelings of incompetence rather than from negative attitudes. Other barriers in providing appropriate care to young people with mental health problems were identified such as lack of time, lack of privacy, lack of human resources, lack of trained professionals and difficulties in communicating with young people. The primary health care (PHC) professionals suggested different solutions to improve care for young people with suicidal problems. CONCLUSION: PHC doctors and nurses in Nicaragua felt that providing skilled mental health services to young people was a priority for them but they also identified a number of barriers to be able to do so. They discussed ways to improve young people's willingness to share sensitive issues with them and suggested ways to make PHC more appreciated by young people.

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Few studies from low- and middle-income countries use qualitative methodology to explore suicidal behavior among young people. In Cambodia, young people face the challenge of rapidly changing times and are vulnerable for suicidal behavior as revealed by research in transitional economies. This study seeks to gain a deeper understanding of the suicidal phenomena from a gender, psychosocial and cultural perspective. Six focus-group discussions were conducted among boys and girls, aged 15-19 years, in two secondary schools in a suburban area close to Phnom Penh, the capital city. The data was analyzed using thematic analysis approach. The participants highlighted the gender difference in suicidal behavior by describing the suicide-prone, acting-out male as 'plue plun', while suicide-prone females were described as caught in constricted, tunneled-thinking behavior, expressed as 'kath klei'. Parental attitude and family environment were also pointed out as the chief causes of discontent and there was a strong wish on the part of young people to find space for modern values within the traditional family. The young people's awareness of their challenges in everyday life suggests that school-based programs to prevent suicidal behavior ought to be gender-sensitive and peer-focused.

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BACKGROUND: People with severe mental disorders (SMD) are at higher risk of suicide. However, research into suicide attempts and completed suicide in people with SMD in low- and middle-income countries is mostly limited to patients attending psychiatric facilities where selection bias is likely to be high. METHODS: A population-based cohort of 919 people with SMD from rural Ethiopia (who received standardized clinician diagnoses of schizophrenia (n = 358) major depressive disorder (n = 216) and bipolar I disorder (n = 345)) were followed up annually for an average of 10 years. The Longitudinal Interval Follow-up Evaluation chart was administered by psychiatrists and used to evaluate systematically suicidal behavior and risk factors, which may be amenable to intervention. RESULTS: Over the follow-up period, the cumulative risk of suicide attempt was 26.3% for major depression, 23.8% for bipolar I disorder and 13.1% for schizophrenia, (p < 0.001). The overall incidence of completed suicide was 200.2/100,000 person-years (CI = 120.6, 312.5). Hanging was the most frequent method used (71.5%) for both attempters and completers. Most people who completed suicide were successful on the first attempt (84.2%), but the case-fatality rate for suicide attempt was 9.7%. In the adjusted logistic regression model, being currently married (Adjusted OR) =2.17, 95% CI = 1.21, 3.91), and having a diagnosis of bipolar I disorder (Adjusted OR = 2.59, 95% CI = 1.57, 4.26) or major depression (Adjusted OR = 2.71, 95% CI = 1.60, 4.58) were associated significantly with increased risk of suicide attempts. CONCLUSION: In this sample of people with SMD from a rural setting, the rate of suicide was high. Initiatives to integrate mental health service into primary care need to focus on limiting access to suicide methods in people with SMD in addition to expanding access to mental health care.

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BACKGROUND: Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills. METHOD: Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M=92, F=76) received 6 sessions of life skills education and in the control school 131 students (M=53, F=78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group). RESULTS: The girls showed improvement in Human Relationship (ES=0.57), Health Maintenance (ES=0.20) and the Total Life Skills Dimensions (ES=0.24), whereas boys with high-risk behavior improved on Human Relationship (ES=0.48), Purpose in Life (ES=0.26) and Total Life Skills Dimensions (ES=0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES=0.40), Attention problems (ES=0.46), Rule breaking behavior (ES=0.36), Aggressive behavior (ES=0.48) and Externalizing syndrome (ES=0.64). CONCLUSION: Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

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BACKGROUND: Whereas prevalence of suicidal expressions among young people is fairly similar in different countries, less is known about associated risk factors. This study compares young people in Nicaragua and Cambodia to examine if the pattern of association between mental health problems and suicidal expressions differs. METHODS: 368 and 316 secondary school students, from each country respectively, participated. Self-reported suicidal expressions, exposure to suicidal behavior in significant others and mental health problems among the students were measured using Attitude Towards Suicide (ATTS) and the Youth Self-Report (YSR) questionnaires. RESULTS: Prevalence of serious suicidal expressions (plans and attempts) during recent year, did not differ between countries. Cambodian young people scored significantly higher on all eight YSR-syndromes, except for withdrawn/depressed. In Nicaragua, all YSR-syndromes were significantly associated with serious suicidal expressions in both genders compared to Cambodia where only one syndrome showed an association in each gender; Withdrawn/depressed among girls and Somatic complaints among boys. Associations between being exposed to suicide among significant others and serious suicidal expressions also differed between Cambodia and Nicaragua. CONCLUSIONS: While the magnitude of serious suicidal expressions is similar between these structurally similar but culturally different countries, determinants behave differently. Qualitative studies are warranted to further explore cultural specific determinants for suicidal expressions among young people.

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BACKGROUND: Schizophrenia is associated with a two to three fold excess mortality. Both natural and unnatural causes were reported. However, there is dearth of evidence from low and middle income (LAMIC) countries, particularly in Africa. To our knowledge this is the first community based report from Africa. METHODS: We followed a cohort of 307 (82.1% males) patients with schizophrenia for five years in Butajira, rural Ethiopia. Mortality was recorded using broad rating schedule as well as verbal autopsy. Standardized Mortality Ratio (SMR) was calculated using the mortality in the demographic and surveillance site as a reference. RESULT: Thirty eight (12.4%) patients, 34 men (11.1%) and 4 women (1.3%), died during the five-year follow up period. The mean age (SD) of the deceased for both sexes was 35 (7.35). The difference was not statistically significant (p = 0.69). It was 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87). Rural residents had lower mortality with adjusted hazard ratio (HR) of 0.30 (95% CI = 0.12-0.69) but insidious onset and antipsychotic treatment for less than 50% of the follow up period were associated with higher mortality, adjusted HR 2.37 (95% CI = 1.04-5. 41) and 2.66(1.054-6.72) respectively. CONCLUSION: The alarmingly high mortality observed in this patient population is of major concern. Most patients died from potentially treatable conditions. Improving medical and psychiatric care as well as provision of basic needs is recommended.

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BACKGROUND: Suicide and suicidal expressions among young people represent a major public health problem worldwide. Most studies are from high-income countries, and it remains unclear whether prevalence and risk factors show a similar pattern in other settings. This study aims to assess the prevalence of suicidal expressions and serious suicidal expressions (ideation, plans and attempts) among adolescents in Nicaragua, in relation to previously reported risk factors, such as exposure to suicide in significant others (parents, siblings, partners or friends) and mental health problems. METHODS: 368 adolescents aged 15-18 years were randomly selected from public secondary schools in León, Nicaragua. Data was collected using Attitude Towards Suicide (ATTS) and Youth Self-Report questionnaires (YSR). Bivariate and multivariate analyses were conducted. RESULTS: Suicide ideation prevalence in the past year was 22.6%, suicide plans 10.3%, and suicide attempts 6.5%. Girls were significantly more likely to report suicidal ideation. Multivariate analyses showed that anxious/depressed, somatic complaints and exposure to suicidal behavior in significant others were significantly associated with own serious suicidal expressions. CONCLUSIONS: The prevalence of serious suicidal expressions among young people in Nicaragua is within the range reported from Western high-income countries. An attempted or completed suicide in someone close, is associated with own suicidal expressions even in the absence of increased mental distress. Furthermore, somatic complaints should alert health care professionals of the possibility of increased suicide risk.

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BACKGROUND: Suicide among young people is a global public health problem, but adequate information on determinants of suicidal expression is lacking in middle and low income countries. Young people in transitional economies are vulnerable to psychosocial stressors and suicidal expressions. This study explores the suicidal expressions and their determinants among high school students in Cambodia, with specific focus on gender differences. METHODS: A sample of 320 young people, consisting of 153 boys and 167 girls between 15-18 years of age, was randomly selected from two high schools in Cambodia. Their self-reported suicidal expressions, mental health problems, life-skills dimensions, and exposure to suicidal behavior in others were measured using the Youth Self-Report (YSR), Life-Skills Development Scale (LSDS)-Adolescent Form, and Attitude Towards Suicide (ATTS) questionnaires. RESULTS: Suicidal plans were reported more often by teenage boys than teenage girls (M=17.3%, F=5.6%, p=0.001), whereas girls reported more attempts (M=0.6%, F=7.8%, p=0.012). Young men scored significantly higher on rule-breaking behavior than young women (p=0.001), whereas young women scored higher on anxious/depression (p=0.000), withdrawn/depression (p=0.002), somatic complaints (p=0.034), social problems (p=0.006), and internalizing syndrome (p=0.000). Young men exposed to suicide had significantly higher scores for internalizing syndrome compared to those unexposed (p=0.001), while young women exposed to suicide scored significantly higher on both internalizing (p=0.001) and externalizing syndromes (p=0.012). Any type of exposure to suicidal expressions increased the risk for own suicidal expressions in both genders (OR=2.04, 95% CI=1.06-3.91); among young women, however, those exposed to suicide among friends and partners were at greater risk for the serious suicidal expressions (OR=2.79, 95% CI=1.00-7.74). Life skills dimension scores inversely correlated with externalizing syndrome in young men (p=0.026) and internalizing syndrome in young women (p=0.001). CONCLUSIONS: The significant gender differences in suicidal expressions and their determinants in Cambodian teenagers highlight the importance of culturally appropriate and gender-specific suicide prevention programs. School-based life skills promotion may indirectly influence the determinants for suicidal expressions, particularly among young women with internalizing syndrome in Cambodia.

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AIMS: The aims were to estimate the prevalence of mental distress in different socio-demographic groups; and to analyze use of health care services among persons reporting mental distress. METHODS: Face-to-face interviews with the Self-Reporting Questionnaires (SRQ-20) were conducted in a sample of 3,425 persons aged 18-60 years. A two-stage probability sampling design was applied to select study subjects. Persons with more than six positive responses to the SRQ-20 were identified as having mental distress. Prevalence was estimated for different socio-demographic groups, and odds ratios of having mental distress were obtained by multiple logistic regression analyses. MAIN FINDINGS: The prevalence of mental distress was 5.4% (6.8% in women and 3.9% in men). Illiteracy and unstable employment status were significantly associated with mental distress among men. Nearly half of those with mental distress had no treatment. Among those who took some health care measures, use of private health services was the most common, followed by self-treatment. Only 5% of those with mental distress sought health care at facilities where mental health care services were available. CONCLUSIONS: Although there was a low prevalence of mental distress, the low use of mental health services indicated that there was a treatment gap in mental health care. Since many people used private services, intervention programs should include private providers to strengthen their capacity to provide mental health care for the community.

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OBJECTIVE: This study explores violence against women in a low-income setting in relation to residency and literacy. SETTING: The study was conducted within the Butajira Rural Health Programme (a Health and Demographic Surveillance Site), which includes rural and semi-urban settings in south-central Ethiopia. DESIGN: This is a community-based cross-sectional study and is part of the WHO Women's Health and Life Events multi-country study. It included 1,994 randomly selected married women. METHODS: A standardised WHO questionnaire was used to measure physical violence, residency, literacy of the woman and her spouse, and attitudes of women about gender roles and violence. Analyses present prevalence with 95% confidence intervals and odds ratios derived from bivariate and multivariate logistic regression models. RESULTS: In urban and rural areas of the study area, the women were of varying ages, had varying levels of literacy and had spouses with varying levels of literacy. Women in the overall study area had beliefs and norms favouring violence against women, and women living in rural communities and illiterate women were more likely to accept such attitudes. In general, violence against women was more prevalent in rural communities. In particular, violence against rural literate women and rural women who married a literate spouse was more prevalent. Literate rural women who were married to an illiterate spouse had the highest odds (Adj. OR = 3.4; 95% CI: 1.7-6.9) of experiencing physical violence by an intimate partner. CONCLUSION: Semi-urban lifestyle and literacy promote changes in attitudes and norms against intimate partner violence; however, within the rural lifestyle, literate women married to illiterate husbands were exposed to the highest risks of violence.

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BACKGROUND: Studies from high-income countries have shown intimate partner violence to be associated with depression among women. The present paper examines whether this finding can be confirmed in a very different cultural setting in rural Ethiopia. METHOD: A community-based cross-sectional study was undertaken in Ethiopia among 1994 currently married women. Using the Composite International Diagnostic Interview (CIDI), cases of depressive episode were identified according to the ICD-10 diagnosis. Using a standardized questionnaire, women who experienced violence by an intimate partner were identified. A multivariate analysis was conducted between the explanatory variables and depressive status of the women, after adjusting for possible confounders. RESULTS: The 12-month prevalence of depressive episode among the women was 4.8% (95% CI, 3.9% and 5.8%), while the lifetime prevalence of any form of intimate partner violence was 72.0% (95% CI, 70.0% and 73.9%). Physical violence (OR = 2.56, 95% CI, 1.61, 4.06), childhood sexual abuse (OR = 2.00, 95% CI, 1.13, 3.56), mild emotional violence (OR = 3.19, 95% CI, 1.98, 5.14), severe emotional violence (OR = 3.90, 95% CI, 2.20, 6.93) and high spousal control of women (OR = 3.30, 95% CI, 1.58, 6.90) by their partners were independently associated with depressive episode, even after adjusting for socioeconomic factors. CONCLUSION: The high prevalence of intimate partner violence, a factor often obscured within general life event categories, requires attention to consider it as an independent factor for depression, and thus to find new possibilities of prevention and treatment in terms of public health strategies, interventions and service provision.

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The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

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This study examines suicide intent among parasuicide patients in a low-income country, Nicaragua, with special reference to gender patterns and future suicidal behavior. Using the Suicide Intent Scale (SIS), suicide intent was assessed in 204 persons presenting to hospital after parasuicide. Repetition was checked after a mean follow-up period of three years. The total SIS scores did not differ between women and men. However, a higher SIS score among women was significantly associated with older age, having children and use of pesticide as the parasuicide method. The overall method of suicide intent was low in Nicaragua compared to other countries, as was the nonfatal repetition rate (4.8% after three years). Subsequent suicides were found only in three men. Factor structures within the SIS disclosed supported the cross-cultural validity of the instrument. The level of suicide intent at the index attempt did not show any association with future suicidal behavior.

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