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Estimating Clinically Relevant Mental Disorders in a Rural and an Urban Setting in Postconflict Timor Leste
Derrick Silove, MD, FRANZCP;
Catherine Robina Bateman, MBChB, MSc;
Robert T. Brooks, PhD;
C. Amaral Zulmira Fonseca;
Zachary Steel, MClinPsych;
James Rodger, MBChB;
Ian Soosay, MBChB, MSc, MRCPsych;
Greg Fox, MBBS, MIPH;
Vikram Patel, PhD, MRCPsych;
Adrian Bauman, PhD, FAFPHM
Arch Gen Psychiatry. 2008;65(10):1205-1212.
Context Epidemiologic studies undertaken in postconflict countries have focused primarily on trauma-related disorders. There is a need to include disabling psychotic disorders in order to plan clinical services in these settings.
Objectives To estimate the prevalence of key clinical disorders in Timor Leste (East Timor), and to assess cultural factors that may influence help-seeking patterns.
Design, Setting, Participants A 2-phase total population survey of 1544 adults in an urban and a rural area of Timor Leste. Phase 1 involved a household informant survey using indigenous terms to detect psychosis and a screen of all adults for posttraumatic stress disorder (PTSD) and symptoms of psychologic distress, including depression and anxiety. In phase 2, clinicians interviewed all those identified by household informants and half of those who screened positive in order to assign DSM-IV diagnoses. Disability, explanatory models, and perceived needs were also assessed.
Main Outcome Measures Phase 1: Demographic characteristics; trauma events and PTSD (Harvard Trauma Questionnaire); psychologic distress (Kessler-10 scale). Phase 2: Structured Clinical Interview for relevant DSM-IV diagnoses; the Global Assessment of Functioning Scale and the World Health Organization Disability Assessment Scales; and the modified Short Explanatory Model Interview.
Results The household informant method in phase 1 detected mainly psychotic disorders, and the screen method detected PTSD and depression. Phase 2 yielded a DSM-IV point prevalence estimate of 5.1% (including psychosis, 1.35%; and PTSD, 1.47%). Psychotic disorders were most disabling, primarily attributed to supernatural causes and treated mainly by traditional healers. Those with depression and PTSD experienced substantial disability but had received little treatment. They attributed their mental problems to social and traumatic causes.
Conclusions Our 2-phase method proved effective for identifying the range of disorders relevant to planning clinical services in postconflict developing countries. The unmet needs of the mentally ill in countries such as Timor Leste pose a major challenge to psychiatry.
Author Affiliations: Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia (Drs Silove, Bateman, Brooks, Rodger, and Soosay, Ms Fonseca, and Mr Steel); Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia (Dr Fox); London School of Hygiene and Tropical Medicine, London, England (Dr Patel); and School of Public Health, Sydney University, Australia (Dr Bauman).
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