Treatment gap and barriers for mental health care: A cross-sectional community survey in Nepal.

CONTEXT: There is limited research on the gap between the burden of mental disorders and treatment use in low- and middle-income countries. OBJECTIVES: The aim of this study was to assess the treatment gap among adults with depressive disorder (DD) and alcohol use disorder (AUD) and to examine possible barriers to initiation and continuation of mental health treatment in Nepal. METHODS: A three-stage sampling technique was used in the study to select 1,983 adults from 10 Village Development Committees (VDCs) of Chitwan district. Presence of DD and AUD were identified with validated versions of the Patient Health Questionnaire (PHQ-9) and Alcohol Use Disorder Identification Test (AUDIT). Barriers to care were assessed with the Barriers to Access to Care Evaluation (BACE). RESULTS: In this sample, 11.2% (N = 228) and 5.0% (N = 96) screened positive for DD and AUD respectively. Among those scoring above clinical cut-off thresholds, few had received treatment from any providers; 8.1% for DD and 5.1% for AUD in the past 12 months, and only 1.8% (DD) and 1.3% (AUD) sought treatment from primary health care facilities. The major reported barriers to treatment were lacking financial means to afford care, fear of being perceived as "weak" for having mental health problems, fear of being perceived as "crazy" and being too unwell to ask for help. Barriers to care did not differ based on demographic characteristics such as age, sex, marital status, education, or caste/ethnicity. CONCLUSIONS: With more than 90% of the respondents with DD or AUD not participating in treatment, it is crucial to identify avenues to promote help seeking and uptake of treatment. Given that demographic characteristics did not influence barriers to care, it may be possible to pursue general population-wide approaches to promoting service use

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal.

BACKGROUND: Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). METHOD: Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. RESULTS: Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, β = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, β = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). CONCLUSION: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone

“All is Normal”: Sports Mega Events, Favela Territory, and the Afterlives of Public Security Interventions in Rio de Janeiro

This article discusses the changes in Visionário, a favela located near the affluent neighborhoods in Rio de Janeiro, to assess the effects of the Sports Mega Events (SMEs) on the political and economic conditions in the favela. Following Harvey’s (2005) description of “accumulation by dispossession,” several authors have highlighted that the UPP policing program, implemented before the SMEs, was part of neoliberal efforts to colonize favela territory with the prospect of future gain. Visionário has witnessed two consecutive policing programs (GPAE and UPP) in the past twenty years. Both were aimed at disarming the drugs-gang members who attempt to rule the favela by force. The ethnography in this article shows that both policing programs started ambitiously, yet gradually police officers withdrew and gang members reoccupied strategic positions in the favela. As a result, residents learnt to deal with ongoing territorial shifts in a highly dense urban space and with the liminal presence of police officers. In my analysis, I argue that in terms of neoliberal strategies to accumulate favela territory by dispossession, this case suggests a failure, and I analyze the struggle over favela territory as the outcome of contradictory forces connected to global neoliberalization

Doing good: Local and global understandings of Buddhism in Hong Kong’s umbrella movement

In this paper, I present Hong Kong Buddhism as a construct of modernity, particularly and paradoxically in its emphasis on tradition. 'Modern Buddhism' shapes how Buddhists in Hong Kong reflect on their religion and their being in the world. The latter is seen in how Hong Kong Buddhists responded to the 2014 Umbrella Movement. Although the Umbrella Movement was in essence a political movement seeking universal suffrage, it indirectly highlighted the importance of religion in the everyday lives of Hong Kong middle-class residents. While some Buddhists went to the protest sites, others stayed at home to meditate, and many decided to disengage from the protests altogether. While differing in terms of civic engagement, there is significant similarity in these narratives regarding the perception of how to act as ‘good’ Buddhists

Family farmers between re-localisation and co-production

Rural sociology and anthropology have developed a sizeable scholarship on “alternative food networks”, which value short supply chains. What are the limits and potentials of becoming involved in alternative food networks? This is sometimes unclear for smallholders and family farms. In this article, I explore the different forms of collaboration that can ensue between “provisioning activists” and local farmers, within a rather complex and fragmented scenario of localised interventions; the article focusses on discourses and practices of food re-localisation, which include many kinds of food “producers” and “coproducers”

The Political Influence of the Latin American Military

Latin America has been and maybe still is the continent of political soldiers and military politicians. In this essay I follow the military’s professional evolution, its involvement in society and politics, and the dual engagement in external and internal security. Since colonial times the Latin American armies were and are in charge of confronting external threats and internal enemies. The paradoxical duality of military professionalism and political ‘calling’ is a recurrent theme during the last 65 years. I make a distinction of political armies of the Right and the Left. In both cases a kind of ‘military mystique’ prevails, but its content is different. In both cases the military justify their involvement in politics as a ‘calling’ based on their vanguard role in politics and society. The two characteristics of dual tasks (internal and internal security) and dual pathways (military professionalism and political involvement) are a revolving theme in this paper. The substance of this contribution is divided in four sections (1) the basic characteristics; (2) political armies of the Right and the Left; (3) the military in democratic Latin America; and (4) new security agendas and ‘unconventional’ counterinsurgency. In the conclusions I reflect on these striking particularities of the Latin American military ethos

Las Fuerzas Armadas en América Latina desde la Guerra Fría hasta el presente: Un ensayo de interpretación

Durante largas décadas en la Guerra Fría, las Fuerzas Armadas en América Latina han sido involucradas en la arena política. La fórmula más conocida era de dictaduras institucionales (implementadas por las tres ramas militares: Ejército, Marina y Fuerza Aérea): gobiernos militares o cívico-militares conocidos como “regímenes de seguridad nacional”, gobiernos de la derecha militar, autoritarios, represivos y contrainsurgentes. Lo que eran menos conocidos eran las llamadas “dictablandas”: regímenes militares autoritarios, pero de carácter reformista y, en general, respetando el orden constitucional. En ambas formas los dirigentes militares se autocalificaron como “revolucionarios”. La intromisión en el ambiente político se justificaba como obligación moral por la “vocación salvadora” incorporada en la “mística militar”. Esta vocación implicaba la necesidad de combatir amenazas nacionales y reajustar el desarrollo económico y político según los intereses básicos de la nación. Hay siete secciones en este ensayo: introducción; doctrinas e ideología; gobiernos militares de la derecha; gobiernos militares de la izquierda; formaciones paramilitares; democracia y misiones nuevas; y democracias violentas