An intervention to improve mental health care for conflict-affected forced migrants in low-resource primary care settings: a WHO MhGAP-based pilot study in Sri Lanka (COM-GAP study).

BACKGROUND: Inadequacy in mental health care in low and middle income countries has been an important contributor to the rising global burden of disease. The treatment gap is salient in resource-poor settings, especially when providing care for conflict-affected forced migrant populations. Primary care is often the only available service option for the majority of forced migrants, and integration of mental health into primary care is a difficult task. The proposed pilot study aims to explore the feasibility of integrating mental health care into primary care by providing training to primary care practitioners serving displaced populations, in order to improve identification, treatment, and referral of patients with common mental disorders via the World Health Organization Mental Health Gap Action Programme (mhGAP). METHODS/DESIGN: This pilot randomized controlled trial will recruit 86 primary care practitioners (PCP) serving in the Puttalam and Mannar districts of Sri Lanka (with displaced and returning conflict-affected populations). The intervention arm will receive a structured training program based on the mhGAP intervention guide. Primary outcomes will be rates of correct identification, adequate management based on set criteria, and correct referrals of common mental disorders. A qualitative study exploring the attitudes, views, and perspectives of PCP on integrating mental health and primary care will be nested within the pilot study. An economic evaluation will be carried out by gathering service utilization information. DISCUSSION: In post-conflict Sri Lanka, an important need exists to provide adequate mental health care to conflict-affected internally displaced persons who are returning to their areas of origin after prolonged displacement. The proposed study will act as a local demonstration project, exploring the feasibility of formulating a larger-scale intervention study in the future, and is envisaged to provide information on engaging PCP, and data on training and evaluation including economic costs, patient recruitment, and acceptance and follow-up rates. The study should provide important information on the WHO mhGAP intervention guide to add to the growing evidence base of its implementation. TRIAL REGISTRATION: SLCTR/2013/025

Associations between socioeconomic factors and depression in Sri Lanka: The role of gene-environment interplay

Background: Low socioeconomic status is a risk factor for depression. The nature and magnitude of associations can differ cross-culturally and is influenced by a range of contextual factors. We examined the aetiology of so-cioeconomic indicators and depression symptoms and investigated whether socioeconomic indicators moderate genetic and environmental influences on depression symptoms in a Sri Lankan population.Methods: Data were from a population-based sample of twins (N = 2934) and singletons (N = 1035) in Colombo, Sri Lanka. Standard of living, educational attainment, and financial strain were used to index socioeconomic status. Depression symptoms were assessed using the Revised Beck Depression Inventory. Structural equation modelling explored genetic and environmental influences on socioeconomic indicators and depression symptoms and moderation of aetiological influences on depression symptoms by socioeconomic status.Results: Depression symptoms were associated with lower standard of living, lower educational attainment, and financial strain. Sex differences were evident in the aetiology of standard of living, with a small contribution of genetic influences in females. Educational attainment was moderately heritable in both males and females. Total variance in depression was greater among less socioeconomically advantaged individuals. Modest evidence of moderation of the aetiology of depression by standard of living and education was observed.Limitations: While the sample is representative of individuals living in Colombo District, it may not be repre-sentative of different regions of Sri Lanka.Conclusions: The aetiology of depression varies across socioeconomic contexts, suggesting a potential mechanism through which socioeconomic disadvantage increases the risk for depression in Sri Lanka. Findings have im-plications for cross-cultural investigations of the role of socioeconomic factors in depression and for identifying targets for social interventions

Prolonged Internal Displacement and Common Mental Disorders in Sri Lanka:The COMRAID Study

Evidence is lacking on the mental health issues of internally displaced persons, particularly where displacement is prolonged. The COMRAID study was carried out in year 2011 as a comprehensive evaluation of Muslims in North-Western Sri Lanka who had been displaced since 1990 due to conflict, to investigate the prevalence and correlates of common mental disorders.A cross-sectional survey was carried out among a randomly selected sample of internally displaced people who had migrated within last 20 years or were born in displacement. The total sample consisted of 450 adults aged 18-65 years selected from 141 settlements. Common mental disorders (CMDs) and post-traumatic stress disorder (PTSD) prevalences were measured using the Patient Health Questionnaire and CIDI sub-scale respectively.The prevalence of any CMD was 18.8%, and prevalence for subtypes was as follows: somatoform disorder 14.0%, anxiety disorder 1.3%, major depression 5.1%, other depressive syndromes 7.3%. PTSD prevalence was 2.4%. The following factors were significantly associated with CMDs: unemployment (odds ratio 2.8, 95% confidence interval 1.6-4.9), widowed or divorced status (4.9, 2.3-10.1) and food insecurity (1.7, 1.0-2.9).This is the first study investigating the mental health impact of prolonged forced displacement in post-conflict Sri Lanka. Findings add new insight in to mental health issues faced by internally displaced persons in Sri Lanka and globally, highlighting the need to explore broader mental health issues of vulnerable populations affected by forced displacement

The association between emotional eating and depressive symptoms:a population based twin study in Sri Lanka

This study investigated the genetic and environmental contributions to emotional overeating (EOE) and depressive symptoms, and their covariation, in a Sri-Lankan population, using genetic model-fitting analysis. In total, 3957 twins and singletons in the Colombo Twin and Singleton Study-Phase 2 rated their EOE behaviour and depressive symptoms, which were significantly associated (men: r = 0.11, 95% confidence interval (CI) 0.06-0.16, women: r = 0.12, 95% CI 0.07-0.16). Non-shared environmental factors explained the majority of variance in men (EOE e2 = 87%, 95% CI 78-95%; depressive symptoms e2 = 72%, 95% CI 61-83%) and women (EOE e2 = 76%, 95% CI 68-83%; depressive symptoms e2 = 64%, 95% CI 55-74%). Genetic factors were more important for EOE in women (h2 = 21%, 95% CI 4-32%) than men (h2 = 9%, 95% CI 0-20%). Shared-environmental factors were more important for depressive symptoms in men (c2 = 25%, 95% CI 10-36%) than women (c2 = 9%, 95% CI 0-35%). Non-shared environmental factors explained the overlap between depressive symptoms and EOE in women but not in men. Results differed from high-income populations, highlighting the need for behavioural genetic research in global populations

Internal Displacement of Northern Muslims in Sri Lanka.

<p>Areas of origin, displacement routes and post-displacement resettled areas are shown.</p

Socio-demographic characteristics and CMD prevalence.

<p>Socio-demographic characteristics and CMD prevalence.</p

Logistic regression analyses of associations between socio-demographic factors and CMD.

a<p><i>Model 1 - Adjusted for all variable excluding employment.</i></p>b<p><i>Model 2 - Adjusted for all variables including employment.</i></p><p><i>Note: McFadden's R² for Model 1 = 0.1135, McFadden's R² for Model 2 = 0.1421.</i></p