This report is provided by the international organization vivo in cooperation with Deutsche Gesellschaft f�r Technische Zusammenarbeit (GTZ). vivo is an alliance of professionals experienced in the fields of psychotraumatology, international health, humanitarian aid, scientific laboratory and field research, sustainable development and human rights advocacy. vivo is an independent non-profit organization committed to the provision of services to those who need it most - regardless of their racial, ethnic, sexual, religious or political affiliations (e-mail: [email protected], homepage: www.vivo.org)
Preface
One morning during our stay in Hargeisa while we were driving to our daily 7:30 meeting we observed a tall women walking on the main road towards the center of town. Her hair was covered with a simple scarf; in one hand she carried waterbottle, in the other a metal chain. The chain was attached to the wrists of a man about 20 years of age, smaller and thinner than his guide. He followed her, his eyes turned to the ground, silently, weak. Only later we learned that mother and son had come to town from a remote rural village because they heard that German doctors had arrived in Hargeisa who would treat people with mental problems. When we saw her first she was searching for us.
All of our radio spots, newspaper articles and thousands of information flyers could not prevent rumors that spread what many people wanted so badly to hear: There would be hope for relief for their dear ones whom they find in despair. This was so despite the very explicit information that we continued to transmit: We have no capacity to offer any help or assistance, there is no registration for mentally sick people, we just carry out an assessment. Nevertheless desperate people continued to seek help, dozens every day, and they brought their mentally ill relatives hoping for relieve.
Daily encounters as the one with the mother and her son put vividness to horrifying data obtained by systematic surveys: Somaliland most urgently needs that the mental health problem be solved in a rigorous, systematic and scientifically sound way. With the present report we hope to draw attention to a problem not yet adequately acknowledged by national and international decision makers. Our Somaliland collaborators and friends, the families of thousands of mentally ill persons together with vivo and GTZ experts hope that international aid agencies will finally start to proceed in this issue.
Konstanz, Cupramontana, December 2002
The vivo team
Acknowledgements
Special thanks to the team of the GTZ office Hargeisa: Innumerable hours of additional work, sometimes until very late, helped us to finalize this project. We express our deep gratitude to (alphabetical order):
Brigitt Hotz (Hotzi) Mohamed Farah (Gafote)
Mustafa Abdi, Khadra Aadan
Rashid Shomari Brown, Zeinab Mohamed
The vivo team is grateful to have received continuous excellent support from local Somaliland collaborators. Without their contribution and efforts our mission would not have been possible. We gratefully acknowledge the contribution of (alphabetical order):
Askar Farah Jireh (Team Leader)
Axmed Cabdi Muse (Interviewer)
Barkhad Biixi Mire (Interviewer)
Cabdillahi Xaaji Xirsi (Team Leader)
Cawil Xasan Liibaan (Supervisor, Interpreter)
Farhan Hassan Omar (Therapist, Local Expert)
Fu'aad Cabdi (Interpreter)
Khadra Aden (Junior Local Expert)
Maxamuud C/llahi Cawad (Interviewer, Interpreter)
Jama Mohamoud (Driver)
Khadiija Cabdillahi (Interviewer)
Maryan Xasan Daahir (Interviewer)
Maxamed Cali Cawad (Interviewer)
Mustafe Xuseen Xirse (Interviewer)
Muuna Muse Diini (Interviewer)
Sacaada Xaashi Jimcaale (Interviewer)
Xamda Aadan Maxamed (Interviewer)
Xuseen Cali Noor (Team Leader)
Zeinab Mohamed (Senior Local Expert, Therapist)
We also are indebted to vivo's scientific advisory board and in particular to Prof. Dr. Dr. h.c. mult. Heinz H�fner, Dr. med. K. Pr�pster and Prof. Dr. Brigitte Rockstroh for their untiring scientific and medical guidance and advice.
Executive Summary
1. The assessment of a representative sample of 612 households in Hargeisa, Somaliland led to the following findings:
- 21% of the surveyed households in Hargeisa care for at least one family
member with severe mental health problems.
- Lifetime prevalence for the most severe forms of mental disorders amounts to
3,5%.
- 15% of the ex-combatants found in the household assessment suffer a severe
mental disorder (mostly psychosis). According to this survey ex-combatants
are four times more likely to suffer from this severe and incapacitating mental
disorder than the already high prevalence in the general Somaliland
population. Ex-combatants are also two times more likely to be affected than
civilian war survivors.
- The very high prevalence of 2,8% of patients with an acute schizophrenia-like
psychosis in the current survey, the unusual ratio between men and women,
and the particular type and severity of symptoms lead us to conclude that these
individuals do not suffer from schizophrenia, but from a crippling psychosis
that must be induced by the particular circumstances in this country. Khat
abuse was excessive in 80% of the cases with this type of psychosis particularly
before the onset of symptoms, in contrast to the khat consumption of healthy
volunteers of the same age. Furthermore, patients started chewing khat about 4
years earlier in their lives than controls did. For these reasons we believe that it
what we see is a tragic epidemic of a khat-induced form of psychosis.
- The findings lend further support to our earlier notion that there is a link
between traumatic stress, khat intake, and resulting drug-induced psychotic
disorder. In short, the mental suffering brought about by traumatic
experiences augments drug intake to overcome the painful memories, the
symptoms of post-traumatic stress disorders, grief, and depression. The local
drug khat induces a psychosis which, in contrast to other types of drug
induced psychosis, does not easily remit after withdrawal from the drug but
leaves the victim in a vulnerable and presumably sometimes permanent acute
psychotic state.
2. In a first phase of the psychotherapeutic treatment study for Posttraumatic Stress
Disorder (PTSD) the following preliminary findings can be reported:
- First data on the efficacy of Narrative Exposure Therapy (NET) are
encouraging. However, at the time of the writing of this report, follow-up data
have not been available and consequently, statements about symptom
reduction, and usefulness would be premature.
3. Special recommendations for the DRP:
This survey confirms the earlier finding that mental health of ex-combatants is a
big concern for the DRP. Large numbers of the beneficiaries suffer some form of
mental and/or physical impairment. If DRP is to succeed in its reintegration
efforts, than mental health problems of ex-combatants need to be addressed
urgently and an adequate mental health program needs to be established.
- It is recommended that a Health Officer position be created. This person will
have mental health expertise within a DRP Health Section, and will be able to
provide outreach services through social workers.
- It is recommended that The DRP Health Section be piloted as a model for
community mental health centers all over Somaliland. Therefore, it is
recommended that the DRP Health Section be situated outside the DRP
infrastructure and transferred to the public health sector during the project
phase.
- Community agencies (i.e., local NGOs, women's groups, CBOs) must be
involved in mental health service provision from the start in order to increase
local capacity and ensure ownership and sustainability in the long-term.
- Evaluation of activities of the DRP Health Section and further studies: In the
view of the pioneering and innovative character of the recommended psychosocial
activities, the DRP Health Section should be accompanied by regular
data-based assessment to estimate the efficacy of the measures undertaken.
The urgent needs of Somaliland will require the development of new and powerful mental health and psychosocial programs in the field of demobilization and reintegration of ex-combatants. Once available, these types of programs can be replicated in other war-torn countries in regions such as East Africa.
4. General recommendations:
- Development of community-based mental health services for ex-combatants
(e.g. support to households who care for mentally impaired persons,
ambulatory treatment services, etc)
- Enabling existing inpatient treatment centers to provide qualified services:
capacity building, training of staff, allocation of resources.
- Development of culturally adequate treatment procedures, including drug
rehabilitation.
- Awareness raising in the general population on mental disorders and the risk
factors in relation to out-of-control khat intake (e.g. early onset of drug intake
in children, "speed runs" with excessive day and night chewing in
adolescents etc.).
- Independent assessment of economic and social consequences of khat
business and intake for Somaliland and assessment of economic alternatives
to khat trade.
1. Introduction
1.1 Historical and political Background of Somaliland
Somaliland refers to the internationally unrecognized but self-declared independent country `Somaliland', which geographically consists of the territory of the former British protectorate Somaliland, the North-Western part of today's Republic of Somalia with borders to Djibouti and Ethiopia.
In the 19th century the colonial powers of Great Britain, France and Italy and the Abysinnian Empire divided the land of the Somali people, which had not existed as a state-like territory before into five parts.
In 1960 the British protectorate Somaliland (capital Hargeisa) became an independent country and unified after a few days with the former Italian colony and trusteeship Somalia (capital Mogadishu), the larger Southern part of today's Somalia, to form together the Republic of Somalia (capital Mogadishu). For the first nine years this state developed in a democratic way. In 1969 Major-General Mohamed Siyad Barre, of the Southern Somali Darod clan, came to power and established a military dictatorship. During the 1980s armed opposition groups grew up all over the country, one of which was the Somali National Movement (SNM), which had the aim of restoring the territory of the former British Somaliland as an independent country. There were many reasons for the growing opposition in the North-Western part of Somalia, but one crucial factor was the suppression of the Isaq clan (whose members constitute the majority of the population of the North- Western part of Somalia) by the central government in Mogadishu. With the support of its mighty neighbor Ethiopia - who allowed the installation of training camps, military bases and supply routes on its territory - the SNM could operate with growing success during the 80s in the North of Somalia.
When the SNM invaded the towns of Hargeisa and Burao in 1988 the Somalia National Army responded by bombing the towns with airplanes, starting and landing from the airport of Hargeisa itself and destroying it almost completely. Isaq clan members in the National Army and in the civil population were victims of massacres at that time. After these incidents in 1988, what had previously been considered a guerilla fight became an open war, and hundreds of thousands of civilians fled to neighboring countries where they have stayed for years in refugee camps. In the Southern and central regions of Somalia other armed opposition groups brought the fight to all areas of the country and to the capital Mogadishu. In January 1991, after the SNM had cut the supply route for the units of the National Army in the North-Western part of Somalia, Hargeisa and the other principal towns in Somaliland fell without further fighting into the hands of the SNM rebels. Subsequently, the National Government in Mogadishu resigned and Siyad Barre fled the country, leaving behind a vacuum of power that led to fights between the different armed groups and a dramatic humanitarian situation, which preceded the international intervention in the following years.
The sudden end of the war in early 1991 found the SNM and the local communities in North-Western Somalia totally unprepared. Almost all basic infrastructure and public institutions were destroyed, large numbers of returnees crowded the towns, hundreds of thousands of mines were left lying in the ground and heavy and small arms were universally present. Soon, large parts of the SNM demobilized themselves, clan militia began to control airports, the port of Berbera and transit roads. Groups of armed young men on the streets represented a real danger to public and private security and were obstacles to peace and economic development. Furthermore, the uncontrolled consumption of khat (a psycho-active local drug) made the situation even more explosive.
Soon after the war, a peace and reconciliation process started with several National Conferences held in the town of Burao. Outcomes of this process were a declaration to end the voluntary union of Somaliland with the former Italian Somalia, and the formation of a transitional administration led by the SNM. However, violence and instability characterized the two year transitional period. In 1993 several meetings of the Somaliland clan elders in Burao, Sheik and Borama significantly advanced the process of negotiation and conflict resolution between different factions. Main results were the formation of the Somaliland Armed Forces, which integrated about 15,000 (of a total 50,000) clan-based militiamen, former SNM fighters and armed men belonging to other groups, and the distribution of political power between clans. Another result of the conference was that Mr. Ibrahim Egal was appointed president. However, he extended his mandate several times, with the help of the majority of parliament against the opposition of some clans in the Eastern part of the country until 2003. Nevertheless, in 1994 and 1995 severe fights between clans re-surfaced and the clan elders had to start another round of negotiation, which has been successful in maintaining peace until today. Several times after 1995, the clan elders had to intervene and start negotiations in order to prevent a new outbreak of violence. One major step in the country's democratic development was the elaboration and acceptance of a constitution for Somaliland in a general referendum in 2001. On 3rd May , 2002, Pr. Egal died during medical treatment in South Africa. Subsequently, the former vice-president Dahir Riyale Kahin was appointed as the new president. In December 2002 general elections will be held for the first time; six political parties will participate.
1.2 Somaliland Demobilization and Reintegration Program
For several years, the Somaliland National Government has been aware of the fact that the number of currently paid soldiers, policemen and prison officers was too high overall and needed to be diminished in order to restructure the national budgetary policy. The government has therefore decided to reduce the current number of 17.000 men on the government payroll to 12.000. The Somaliland government has actively contacted international agencies to implement a demobilization program. The Somaliland Demobilization and Reintegration Program (DRP) receives funding from the European Community. The implementing agency, the German Agency for Technical Cooperation (GTZ), cooperates with different ministries and the National Demobilization Committee (NDC), to demobilize, as a first step, 800 ex-combatants by the end of 2002. The beneficiaries of the DRP are identified by the different military branches led by the Ministry of Defense The Ministry of Defense provides an authorized list of beneficiaries with whom GTZ is allowed to engage in the different demobilization activities (rural integration, vocational training, small and micro-enterprises, micro-credit, integration in job market). However, several times in the past, concerns about mentally disturbed and aggressive ex-combatants were raised. The identification of mentally disturbed and potentially harmful ex-combatants in large groups of beneficiaries and how to deal with them, became a key question and a determining factor for the overall success of the project. Vivo addressed this question in its first mission (Febr./March 2002) in Hargeisa.
An overview of the target group and its relationship with the SNM fighters is presented in graph 1.
Graph 1: The target group of the Somaliland Demobilization and Reintegration Program (DRP) NDC National Demobilisation Committee. SOYAAL Somaliland Veterans Association
1.3 Special conditions in Somaliland: the khat problem
This issue was extensively addressed in our report of the mission in February/March 2002.
To briefly summarise, khat is a shrub (Catha edulis Forsk.) growing in high altitudes of East African and Arab countries. Its leaves are traditionally chewed because of their stimulating effects. The fresh leaves contain the amphetamine like alkaloid cathinone, which is a central stimulant that is easily and swiftly absorbed by the body while chewing. Cathinone produces similar effects to amphetamine but one can only ingest a relatively small amount by chewing the leaves, compared to amphetamine pills or injections available in Western countries. Several studies have shown deleterious effects of khat chewing but results are inconsistent. Recently, several case reports of khat-induced psychotic reactions have been published. The psychiatric reactions frequently observed in amphetamine addicts have never been systematically studied in the main consumer countries of khat, like Somalia, Ethiopia or Yemen.
This issue deserves special attention in Somaliland because the prevalence of khat chewing is extremely high (Elmi, 1983). The data gathered in our first mission led to the hypothesis that excessive khat chewing in combination with prior traumatization may have especially deleterious effects, such as a higher probability of developing paranoid symptoms, which, in turn, can lead to aggressive outbreaks. The prevalence of khat chewing among the studied sample of ex-combatants was 66% and the amount of consumed khat could partly explain the variation in symptoms. Several authors state that the khat consumption has significantly spread and augmented in the last years because of improved storage and transportation facilities. In Somaliland the khat chewing habit has changed significantly since the start of the war 1988, during which large parts of the population had to flee to Ethiopia and stayed there in refugee camps for many years. The refugee camps were situated in the main khat producing region.
2. Study background
2.1 Previous findings
The first vivo mission in Febr./March 2002 operated solely within the group of identified beneficiaries of the DRP. A random sample was drawn from the identified beneficiaries (Febr. 2002 N = 666) and N = 135 were screened for PTSD by trained local interviewers. To evaluate the quality of this screening procedure, N = 64 of the screened ex-combatants were assessed a second time by vivo experts with the help of Somali interpreters. The main results were:
- 19% of the beneficiaries have PTSD
- 19% of them have significant symptoms of Depression
- 14 % and 16% of the beneficiaries displayed at least on symptom of paranoia and hallucinations
- regular khat chewing was found in 66%
- The combination of khat chewing and PTSD revealed a pattern of symptoms that
led to the hypothesis that PTSD might serve as a vulnerability factor for
developing psychotic symptoms as a consequence of khat intake.
Furthermore, vivo visited N = 22 severely psychiatrically disturbed individuals (mostly ex-combatants) at home and assessed their situation. The main outcome was that families tend to restrain those members (chaining or locking in) who display disruptive behaviors. Men who display aggressive acting out are especially likely to be chained by their families and to stay chronically in chains because of ongoing aggressive behaviors.
The development of sound recommendations on how to assist the identified beneficiaries with PTSD and the more severely affected ex-combatants chained in their homes was not possible with the gathered data and further studies were recommended.
2.2 Terms of Reference
The TOR of the second vivo mission in Hargeisa were based on the findings of the first mission and aimed to clarify some of the remaining and emerging questions.
The planned activities can be divided into two main sections : First, to gather basic data about the mental health situation in Somaliland to enable the interpretation of the data gathered among ex-combatants. Secondly, to conduct initial trials on treatments to assess their feasibility, applicability and effectiveness in the Somali culture.
Therefore, the TOR contained the following activities:
1. Conduct a household assessment in Hargeisa with a representative sample of
households to determine:
a) how many households care for members with severe mental disorders,
b) the prevalence of severe mental disorders among the general population,
c) compare the prevalence of severe mental disorders between the two subgroups
of civilian war survivors and ex-combatants, and
d) estimate the influence of the factors "khat chewing" and "war trauma" on the
development of severe mental disorders, like psychosis.
2. Conduct a first trial of "Narrative Exposure Therapy" (NET), a psychotherapeutic treatment for Posttraumatic Stress Disorder (PTSD) with a small group of beneficiaries with PTSD.
3. As an optional activity a trial on psychopharmacological treatment was included. However, this activity was only to be set in practice if collaboration with local partners on this issue would be possible.
The members of the vivo research team were: Dipl. Psych. Michael Odenwald (head of mission, permanently present during all vivo activities in Somaliland), Dr. Maggie Schauer present twice on missions in Somaliland), cand. phil. Birke Lingenfelder ( present twice on mission in Somaliland), Dipl. Psych. Frank Neuner ( present on second mission in Somaliland), Dipl. Psych Christine Klaschik (present on second mission in Somaliland), Dipl Psych. Claudia Catani (present on second mission in Somaliland), Dr. Rebecca Horn (present on second mission in Somaliland) and Prof. Dr. Thomas Elbert (present in vivo's first mission).
2.3 vivo's working principles
vivo is an international non-governmental organization, committed to helping individuals and communities affected by armed conflict and political violence to overcome and prevent traumatic stress and its consequences. vivo further aims to strengthen local resources for the development of peaceful, human rights-based, societal ways of living. vivo achieves these objectives by the rigorous application of evidence-based research - bridging the gap between current findings in mental and public health science and its practice - and by basing its activities on situationspecific knowledge. vivo subscribes to the organizational ethic, that all recommended solutions must be scientifically valid. All activities are undertaken in collaboration with local individuals and communities. vivo cooperates with national and international organizations, to ensure sustainability and a multiplicatory effect. The organization is an alliance of professionals experienced in the fields of psychotraumatology, international health, humanitarian aid, scientific laboratory and field research, sustainable development and human rights advocacy.
3. Household Assessment/Prevalence Study
3.1 Research Question
One of the basic questions about mental health in Somaliland remained for a long time unanswered: What is the prevalence of severe psychiatric disorders among the general population and among sub-groups? The DRP Somaliland is confronted with the fact that a significant number of its beneficiaries suffer from a severe and incapacitating mental disorder and our first study in February/March 2002 quantified the fraction of people affected with rigorous clinical examinations: about one fifth of the ex-combatants who are beneficiaries of the DRP suffer from PTSD and another fifth from significant symptoms of depression. During the first mission, there was no possibility to compare the mental health of ex-combatants with the general population and consequently, it was not possible to distinguish to what extent this would be a specific problem of ex-combatants or a situation that would affect the people at large. Since this information would obviously be of great value for future planning of the demobilization activities in Somaliland, GTZ/vivo decided that a systematic and careful survey would be needed which drawa data from a representative sample of households in the capital of Somaliland, Hargeisa.
3.2 Methodology
Design
The household assessment comprised two parts. The first part was performed by trained teams of local interviewers and had the aim of identifying people who are suffering from a severe mental disorder. Our interviewers approached more than 600 households, chosen to be representative for all of Hargeisa and gathered information about all members of each household. As a general rule, the head of the household was interviewed first, only if he or she was not present, another adult household member was interviewed. The following data on all household members were collected: age, sex, years of formal education, martial status, war participation as combatant or civilian war survivor, and khat consumption in the last week. To identify whether a person with a mental disorder (called "mental case" in colloquial language) lived in the household, the following two questions were part of each interview:
"Now I would like to ask you if there are any members of your household who currently have mental problems that are so severe that they affect the person in providing income or helping in the household for at least four weeks?" and Are there any other members of your household who had mental problems in the past for at least six months that were so severe that they affected the person in providing income or helping in the household?"
In a second step a clinical expert of the vivo team conducted a structured clinical interview with about 50 of the identified sick people to determine whether an actual mental disorder was present that led the family to label the sick person a "mental case". If the answer was "yes", the mental disorder was categorized using clinical diagnostic procedures and criteria.
Graph 2: Research Design of the Household Assessment in Hargeisa
(Please note: persons who were identified by household members as suffering from mentaldisorders are referred to as
"mental cases" in colloquial language)
Research Design of Household Assessment
Time
Trained local interviewers
Interviewing of represenatative sample of households
Collection of data on all household members
Identification of mentally ill people
Step 1
vivo experts
Clinical examination of a randomly selected percentage of the mentally
sick
Step 2
Random Sampling Method
The challenge of a household assessment is that only a certain proportion of the total number of households can be assessed but the results should be valid for all households. Therefore, serious efforts have to be made to get a sample, which is representative for the total population. The "gold standard" to get a representative sample of the total population is reached through systematic `random sampling'. This ensures that the decision to include a particular household is purely determined by chance whereby each household has the same chance to be included in the survey.
We developed and applied a random methodology in collaboration with UNICEF Hargeisa who conducted a household assessment (evaluation of vaccination campaign for children under five) parallel to our activities and we also applied methods used by IRC in the Interagency Returnee Assessment (Clark, 2002). With the help of the municipality of Hargeisa, the town was divided in thirty sections, with almost equal population size. This division was the basis for establishing maps of each sector using the UNDP aerial photo of Hargeisa, which was made in 19991. In each section 20 households were planned to be included in the sample. Given that a cluster size of 20 households would be too large, we divided each section in one to three independent clusters. These clusters were cautiously drawn in the maps of each section, with borders not overlapping and covering 100% of the section. In each cluster the geographical center served as the starting point for the random selection of households. Positioned at the starting point a watch was adjusted to the map so that 12 o'clock corresponded to the perfect North ("North" was defined as the upper part of the map). By selecting a number from a first random list (numbers between 1 and 12) a random direction was chosen (12 o'clock = North; 6 o'clock = South; 3 o'clock = East; 9 o'clock = West).
In a next step of this random procedure we walked in the chosen direction as approximate as possible (at each crossroad the direction could be adjusted in order to follow more closely the chosen direction). While walking the random direction towards the border of the cluster all households on the right side within a range of 15 m were counted. This counting ended at the border of the cluster. One of the counted households served as the first to be included in the sample. To determine the first household, a second list of random numbers was used. Having determined the first household each third- nearest household (estimating distances from door to door) was included in the sample until the total number of households in a cluster (10) was reached.
Interviewer Teams
For the household assessment we worked with five interviewer teams, each consisting of one male and one female person. Additionally, two team leaders and one supervisor were employed (see graph 3). The interviewer teams entered the households, informed the household members about the purpose of the assessment and conducted the interview if the household agreed to participate. Team leaders were responsible for random sampling, indicating to the interviewer teams which households are included in the sample, controlling the correctness of the questionnaires and informing the population of the different sections of Hargeisa about the assessment. The local supervisor had the task to control and assist the team leaders.
The whole team was trained for two weeks. Contents of the training were: introduction to psychiatric diseases, training on the questionnaire, and training on interviewer conduct. Furthermore all staff was involved in translation, discussion and cultural adaptation of the instruments. Team leaders and local supervisor received additional lessons on random sampling.
Graph 3: Structure of interviewer team
Team 1 Team 2 Team 3
Team Leader 1
Team 4 Team 5
Team Leader 2
Local Supervisor
Instruments
Instruments used in the Household Assessment were standardized questionnaires with predefined answer categories (only one question was an open question). The original instruments are in English language. All instruments were translated to Af Somali, back-translated independently, and corrected. This procedure was repeated as many times as necessary until the back-translation corresponded fully to the original English version. In this process of translation and back-translation extensive discussion with our team lead to modifications and cultural adaptations of the instruments. Before applying the instruments in the household assessment they were subjected to a final pre-test with about 25 households. Please, find the final versions of the instruments in Appendix A.
3.3 Results
In this chapter we present a brief overview of the results. A complete account would be certainly beyond the scope of this report.
This chapter is divided into three paragraphs: The first includes the characteristics of the households and people in our sample, in the second we report the characteristics of the people with severe mental disorders, and in the third the results of the clinical interview conducted with a sub-sample.
3.3.1 Household and sample characteristics
The analysis includes 612 households with 4.854 persons in Hargeisa. The average number of persons per household is 7,9 (range 1 to 22).
Table 1 shows the income of the surveyed households (rated by the interviewers) and the average household sizes. The households are most frequently in the low and medium income class. There are only few households with high or very high income. The average household size is lower in the low income classes.
Table 1: Income (rated by interviewers) of surveyed households
Income Number Number Average size (range)
(percentage) (percentage) of households
of households of all persons
Very low 99 652 6,6
(16%) (13%) (1 - 22)
Low 231 1.791 7,8
(38%) (37%) (2 - 19)
Medium 236 1.983 8,4
(39%) (41%) (2 - 22)
High 39 363 9,3
(6%) (7%) (2 - 17)
Very high 7 65 9,3
(1%) (1%) (8 - 13)
Total 612 4.854 7,9
The average age of persons living in the surveyed households is 22,2 years (SD = 17,8) ranging from newborn babies to a 102 year old person. It has to be mentioned that many people did not know their exact date of birth.
The sample comprised 50,5% male (N = 2.449) and 49,5% female (2.405) individuals. The years of formal education a person has received differed between men and women: Men received on average 3,7 years of schooling (SD = 4,6) whereas women received only 1,6 years (SD = 3,2). The average years of formal schooling in the whole population is 2,6 years (SD = 4,1).
The khat consumption was estimated by the US$ the individual spent in the week before the interview on khat. On average 0,9 US$ were spent on khat per capita (SD = 3,2). However, this may be an underestimation of the actual consumption, as the interviewed household heads often could not tell exactly how much a member would spend: many habitual khat chewers seem to hide their consumption from their relatives. Khat consumption is restricted to men, only few women have been reported to chew. Table 2 summarizes the data.
Table 2: Sample characteristics
Male Female
Number 2.449 2.405
(Percentage) (50,5%) (49,5%)
Age Average 21,8 22,7
(SD) (17,6) (18,0)
Years of education Average 3,7 1,6
(SD) (4,6) (3,2)
Khat consumption in week before
our interview (in US$) Average 1,7 0,05
(SD) (4,3) (0,8)
The following graph shows the frequency distribution of the age in the sample of the
surveyed households (graph 4). 54,7% of the sample has not yet reached the age of
20.
Graph 4: Frequency distribution of age in the sample 612 households.
Frequency distribution: Age of sample. Not available.
Of the total number of persons (N = 4.854) 55 % (N = 2.667) were reported to be civilian war survivors and 5 % (N = 253) to be ex-combatants, whilst 40% did not have any war-experiences.
Graph 5: War experience in our sample of 4.854 persons in Hargeisa.
civilian war 55% survivors ex-combatants 5% no war experience 40%
It is worth mentioning that ex-combatants and civilian war survivors differ from each other and from persons without war experiences. Ex-combatants are on average about 15 years older than civilian war survivors and about 21 years older than those without any war-experiences in their lives. Ex-combatants have received more formal education and spend much more money on khat compared to others.
Obviously, the age differences explain for the different levels of education and khat chewing amongst the three groups. Table 3 summarizes the data. War experience in our sample
Table 3: Characteristics of ex-combatants, civilian war survivors and persons without any war experience among our sample of 4.854 persons in Hargeisa.
Ex-combatants Civilian War No war
Survivors experience
Number 253 2.667 1.934
(Percentage) (5%) (55%) (40%)
Male 242 1.201 1.006
Female 11 1.466 928
Age Average 42,3 28,7 10,8
(SD) (14,1) (16,6) (12,1)
Years of Average 5,1 3,3 1,4
education (SD) (5,6) (4,3) (3,0)
Khat consumption in
the week before our
interview (in US$) Average 5,2 1,0 0,2
(SD) (6,1) (3,5)) (1,3)
3.3.2 Persons with severe psychiatric disorders
Out of all surveyed households 21% care for at least one person who has a severe psychiatric disorder.
In the surveyed households 169 persons with current serious mental problems (according to their families) were detected; another three had serious mental problems in their lives before. In colloquial language all these persons are referred to as "mental cases" or "mentals"2.
In this paragraph we report some of the characteristics of the people we found to suffer currently from a severe mental disorder, some information and statistics about them and their lives. All the information reported in this section is derived from the interviews conducted by our trained Somaliland staff.
Socio-demographic characteristics of "mental cases"
Of the 169 persons with severe mental problems 81,1% (N = 137) are male and 18,9% (N = 32) female. Their average age is 32,2 years, and therefore they are about ten years older than the average person in the general population. "Mental cases" had received on average more years of formal education than the general population: 4,1 years compared to 2,6 years, which is clearly related to the age difference between both groups. They consumed a higher amount of khat in the week before our interview, spending on average 3,4 US$ on it, compared to 0,8 US$ in the general population.
Table 4 on the next page summarizes the characteristics of the persons with severe mental disorders.
The duration of their severe condition was on average 9,0 years (SD = 6,1), ranging from a few months to 29 years.
Table 4: Characteristics of persons with current severe mental disorders.
Persons with current Persons without severe
severe mental disorders mental disorders
Number 169 4.685
Percentage 3,5% 96,5%
Male 137 32
Female 2.312 2.373
Age
Average 32,2 (12,6)
(SD) 21,9 (17,9)
Years of
education Average 4,1 2,6
(SD) (5,1) (4,0)
Khat consumption
in the week before
(in US$) Average 3,4 0,8
(SD) (6,3) (3,0)
Management of severe mental disorders
Like in many other African countries, the families take care of persons with severe mental disorders and often there is little the relatives can do other than to restrain them in order to avoid harm being done to others or themselves.
Of the 169 persons with severe current mental problems 109 had to be chained at some point during their lives and 113 had to be restrained in some other way by their family (mostly because of aggressive behavior). At the time of the interview 48 were kept in chains and 85 were restrained in other ways.
The average time spent in chains of the 109 "mental cases", who had been chained at some point during their lives, was 2,7 years (SD = 3,9) and the average time being restrained in some other way for the 119 of them who had experienced this, was 3,9 years (SD = 5,1).
Most families sought help for their mentally ill members in different places. Most often medical doctors were approached for the prescription of psychotropic drugs (N = 125). However, 62% of them additionally looked for the help of traditional or religious healers: 38% went additionally to a sheikh (religious healer) and 35% of them went to a traditional healer working with herbs. Of the whole group 72 "mental cases" were brought to a sheikh, 63 to a healer working with herbal medicines, and 31 to one who tried to exorcise ghosts.
The effect of the different treatments was regarded by most to be poor or even negative. Medical doctors achieved the best results: 33% of their patients' families reported positive effects. Traditional healers or sheikhs achieved positive effects in less than 10% of their patients. Because psychiatric disorders often have a chronic course, they require maintenance of the treatment for quite a long period of time. Often, family members stated that they could not maintain treatment as long as it had been regarded necessary: Financial constraints led to termination of medical treatment in 67% of the cases. For the same reason, 58% and 54% had to end treatments provided by a sheikh or by a healer working with herbs.
Participation in war
It is widely acknowledged that people who have faced extremely stressful events in the past are more likely to suffer from severe mental disorders later in their lives. In our sample, persons with severe mental disorders often have survived extremely severe war experiences during their lives.
Thirty nine (39) persons who are considered "mental cases" are ex-combatants. This means that 23,1% of the persons with current mental disorder (N = 169) are excombatants, and that 15,4% of the 253 ex-combatants are "mental cases". Thus, about one sixth of the persons who have actively been fighting in a war developed a very severe form of a mental disorder later in their lives. In contrast, 4,2% of the civilian war survivors and 1% of the persons not exposed to war suffer currently from a severe mental disorder. This means also that the risk of becoming a "mental case" is higher for ex-combatants compared to other persons who did not fight actively in the war (see table 5 and graph 6).
Table 5: Number and percentage of "mental cases" among ex-combatants, civilian war survivors, and persons without any war experience.
But ex-combatants are on average twice as old as the rest of our sample (42,3 compared to 21.1 years). Therefore, they have a higher risk of having developed a mental disorder during their lives so far, because the peak in the onset of severe mental disorders is between 15 and 30 years of age. When we repeated the analysis for the men aged 15 or older (N = 1.451, mental cases: N = 133) ex-combatants still have an increased risk of having developed a mental disorder during their lives: 15,9% compared to 8,6% and 3,9% (see table 5 and graph 6).
Percentage
(Number)
of "Mental Cases"
Ex-combatants Civilian Persons Total
war survivors without war
experience
In whole 15,5% 4,2% 1,0% 3,5%
sample (39 of 253) (111 of 2.667) (19 of 1.934) (169 of 4.854)
Men 15 or older 15,9% 8,6% 3,9% 9,2%
(38 of 239) (87 of 1.009) (8 of 203) (133 of 1.451)
Graph 6: Frequency of severe mental disorders among ex-combatants, civilian war survivors and persons without any war experience in Hargeisa. Not available.
Drug consumption and mental disorder
Many of the persons with current severe psychiatric problems have consumed large amounts of khat in the months, weeks and days before the onset of their disorder. However, we could not get the information about khat consumption for all persons with psychiatric disorders because in some cases the caretakers did not know, e.g. if the onset of symptoms happened when the person stayed abroad or if the onset of the disorder was too long ago. The interviewers could get information about khat consumption before the onset of psychiatric symptoms in 62% (N = 104) of the "mental cases". They found out that 64 of 104 persons with severe current psychiatric disorder had an exceptionally high consumption of khat just before the onset of their symptoms (see graph 7).
Graph 7: Exceptionally high consumption of khat in the week before onset of the current psychiatric disorder.
Khat chewing in the week before onset of psychiatric disorder (N = 169)
no excessive khat chewing 38% excessive khat chewing 38% no information 24%
Interviewers also asked how many khat bundles a person had consumed in the week before the onset of symptoms. The average amount consumed by the 124 people for whom this information was available was 11,3 bundles (SD = 10,4), much higher than the average in the general population, which is 0,8 bundles per week (SD = 2,7). Interviewers also asked for the number of nights that a person with mental problems could not sleep in the week before the onset of the disorder. The background to this question is that exceptional khat abuse is often associated with sleeping difficulties and the tendency to chew consecutively several days and nights without sleeping. The average number of sleepless nights in the week before onset for the 106 of them for whom we could get this information was 3,2 (SD = 2,5).
Exceptional khat chewing before the onset of the symptoms was more prevalent among "mental cases" who had been ex-combatants before. 61,5% of the 39 excombatants with mental disorders are known to have chewed an exceptional amount of khat before onset, in comparison to 39,2% of the other 130 "mental cases".
This result underlines that before the onset of psychiatric disorders there was in many cases an exceptional abuse of khat, especially among the former excombatants who suffer from mental disorders.
3.3.3 Clinical interviews with persons with severe psychiatric disorders
We randomly selected 54 of the identified "mental cases" to be assessed more closely with a clinical interview (interview with patient and caretakers). To enable a comparison with the general population we used case-control design, i.e., asked the same questions to healthy volunteers who were matched in relation to age and years of formal education to the "mental cases". vivo team members conducted the interviews with the help of trained interpreters. Each interview with a patient lasted between 1,5 to 3 hours. The interview with healthy volunteers took less time.
Socio-demographic characteristics of interviewed patients
The interviewed patients are on average 33,4 years of age (SD = 13,7) and 85,2% (N = 46) of them are male. On average they had received 4,9 years of formal education (SD = 4,6). Table 7 below summarizes the data.
Psychiatric diagnosis of persons with severe mental disorders
According to ICD-10, 43 of them suffer from a disorder from the schizophrenia
spectrum3, four have a mental disorder due to a general medical or neurological
condition, three are mentally retarded, one child has an Attention Deficit
Hyperactivity Disorder (ADH
d) and two elderly persons suffer from a form of
dementia. Table 6 summarizes the data.
The reasons for there being a restricted range of disorders among the prior identified "mental cases" are not fully clarified. We suppose that other forms of mental disorders, like for example mood disorders (e.g. Major Depression) or anxiety disorders (e.g. Posttraumatic Stress Disorder) do not have such a devastating influence on the social functioning and, therefore, are perceived as less severe by the Somaliland society. For that reason they might not fit the local definition of "mental case" which is used to describe people completely unable to care for themselves. We believe that we only found the most severe mental disorders, leaving less severe "cases" undetected.
Table 6: Percentage of different diagnosis of 54 persons with severe mental disorders.
Number
(Percentage)
of diagnosis
Diagnosis male female total
Schizophrenia 38 5 43
Spectrum Disorder (70,4%) (9,3%) (79,6%)
Neurological 4 - 4
Disorder (7,4%) (7,4%)
Mental Retardation 3 - 3
(5,6%) 2 (5,6%)
Dementia - 2 2
(3,7%) (3,7%)
Other Disorders with 1 - 1
Onset in Childhood (1,9%) (1,9%)
Diagnosis not - 1 1 1
possible (1,9%) (1,9%)
Total 46 8 54
(85,2%) (14,8%) (100%)
The high number of schizophrenia spectrum disorders among the interviewed "mental cases" seems striking, given that in all cultures around the world the lifetime prevalence of schizophrenia is in the range of 1%, (with the exception of a small Pacific Island with a high rate of inbreed where it reaches some 2%. Generally men and women are equally affected. The high number of the patients with symptoms typically associated with schizophrenia in the current sample, and the unusual ratio between men and women, lead to the conclusion that these individuals do not suffer from a schizophrenic psychosis, but from a psychosis that must have been induced. To clarify this question it is important to consider the effects of organic diseases and environmental factors. The most important environmental factor is the consumption of psychotropic drugs. Organic diseases and related psychiatric disorders are already considered in the category "neurological disorders".
In a next step we tried to classify the detected schizophrenic spectrum disorders into those related to khat intake and those not related to khat intake. Related to khat intake means that "positive symptoms" (delusions, hallucinations, thought disorder) appeared the first time after excessive khat chewing and that relapses were related again to khat chewing.
According to this classification, 81,4% (N = 35) of the cases are related to khat intake, i.e., drug-induced. All "cases" in this category are male. The remaining 18,6% of cases with schizophrenia spectrum disorders are almost equally distributed between both sexes (male: N = 3; female: N = 5).
Graph 8: Percentage of diagnosed disorders with excessive khat intake before onset.
Schizophrenic spectrum disorder with excessive khat abuse before onset Proportion of disorders with excessive khat abuse before onset 65% other disorders without khat abuse 20 Schizophrenic spectrum disorder without khat abuse 15
Traumatic experiences and khat intake
We also assessed the frequency of traumatic events in patients and healthy control persons by asking whether the interviewee had experienced 13 different types of events ever during his life. Patients on average experienced 2,6 different types of events (SD = 2,3). Healthy control persons had a slightly higher score, on average 2,8 (SD = 2,4). This difference cannot be regarded statistically significant. See table 7. Patients started chewing khat on average at the age of 16 and healthy control persons 4 years later. This difference can be regarded statistically meaningful. In the months before the onset of their symptoms patients chewed on average 1,7 bundles of khat per day (SD = 2,0). Healthy control persons were asked for their khat consumption at the age of symptom onset of their matched counterpart. Controls chewed much less: 0,3 bundles per day (SD = 0,6). This difference, too, has statistical relevance. (See table 7 on the next page).
Estimates of lifetime prevalence
A rough extrapolation of the numbers derived from our sample leads to an estimated lifetime prevalence for any schizophrenic spectrum disorder of 2.8% in Hargeisa. The severe schizophrenic spectrum disorders after excessive khat chewing have a prevalence of 2,3%. In contrast, schizophrenic disorders without khat chewing have a prevalence of 0.6%. The ratio male:female for the khat related form of the spectrum disorder is 1:0 and for the non-khat related form is 1:1,7. Even though roughly estimated, a prevalence rate of 2,8% is high relative to standard references. Most of the cases reported excessive khat consumption before the onset of symptoms, which suggests a high prevalence of drug-induced disorders with schizophrenia-like symptoms and disability.
Table 7: Characteristics of patients and healthy control persons and statistical significance of differences.
Patients Healthy control Statistical relevance
persons of differences
(N = 54) (N = 54) (p = 0,05)
Male 46 46
Female 8 8 no
Age
Average 33,4 35,1
(SD) (13,7) (13,2) no
Education
Average 4,9 5,3 no
(SD) (4,6) (5,0)
Age when started
khat chewing
Average 16,4 20,1
(SD) (4,1) (7,1) yes
Khat before onset
(bundles per day)
Average 1,7 0,3
(SD) (2,0) (0,6) yes
Number of traumatic
events Average 2,6 2,8 no
(SD) (2,3) (2,4)
3.4 Discussion
Our findings indicate that ex-combatants are more affected by severe mental disorders than other groups of the population. The data also show that civilian war survivors are more likely to suffer from severe mental disorders compared to persons who were not involved in the war.
Disorders of the schizophrenic spectrum are more prevalent in Hargeisa than in other countries. Khat abuse was excessive in most of the severly psychotic cases particularly before the onset of the incapacitating symptoms, in contrast to the consumption of healthy volunteers of the same age. Furthermore, the patients started chewing khat about 4 years earlier in their lives than the controls did. But, the number of traumatic events experienced by patients and healthy controls does not differ.
"Khat induced psychosis"4
The results led us to hypothesize that excessive khat intake is a main predicting factor for the onset of schizophrenia spectrum disorders in Hargeisa. This seems astonishing as khat is viewed as a stimulant with a very low potency compared to amphetamines or cocaine. The main argument against the notion that khat intake can lead to a psychotic reaction is the fact that a person can hardly eat an amount of khat leaves comparable to one single dose of amphetamine (Halbach, 1972). The most prominent model of amphetamine psychosis states that the chronic consumption of relatively high doses lead to the psychotic symptoms (Ellinwood et al., 1973). However, there are other models and research conducted in recent years that allow for alternative explanations.
According to the "low dose continuous intoxication" model of amphetamine psychosis the crucial factor is the time period, for which the blood level is maintained above a certain threshold (Ellison & Eison, 1983; Griffith et al., 1972).
Even small doses of amphetamines (that are consciously unnoticed by participants) can provoke the onset of psychotic symptoms when a certain blood level is maintained over a period of several days. This corresponds to the typical feature of drug abuse we often met in Somaliland: the continuous chewing for more than one day, often across consecutive days even without eating or sleeping; the addicts frequently "cut off" arousal effects by ingesting tranquilizers that are easily available on the market.
Recent publications shed a completely new light on amphetamine effects: under certain conditions a small dose can have the effect of a large dose. These conditions are: new environment (e.g. Crombag et al., 2001; Robinson et al., 1998), and sensitization due to prior drug intake (e.g. Yui et al., 1999), stress pretreatment (e.g. Goeders, 2002; Covington et al., 2001), or previous psychotic disorder (Sato, 1992). This suggests that the traditional view of khat and its potential to provoke psychotic symptoms has to be modified. In the present sample traumatic experience constitutes one of these conditions, which leads to devastating effects of long-term consumption of low potency stimulants. In addition, the role of early onset of khat intake - strongly prohibited in the Somali pre-war society - may play an important role in the psychotic break-down of brain functioning.
We therefore suggest a model that explains our findings (see graph 9 on the next page). Like every amphetamine-like stimulant khat can have the effect of provoking psychotic symptoms. But as a low potency stimulant, only sustained khat consumption can have this effect (frequent chewing for several days in a row without sleeping). At the present state of model development we hypothesize that posttraumatic stress magnifies the deleterious effects of khat so that a pretraumatized person who chews khat excessively has a higher probability of developing a "khat psychosis" compared to an untraumatized person who chews an equal amount of khat.
Graph 9: Vulnerability model for khat induced psychosis. Not available.
4. First Therapy Study on "Narrative Exposure Therapy"
Because the post-treatment assessment is not yet finalized we report here preliminary results.
Persons who have survived extremely stressful events, like combat experiences, torture, serious accidents etc. which involved threat to one's life and feelings of terror and helplessness, frequently develop a psychiatric condition in the consequence. The most prevalent of these conditions is Posttraumatic Stress Disorder (PTSD). PTSD is defined by a set of symptoms (re-experiencing the lifethreatening event, avoidance of reminders and constant hyper-arousal), by impairment in every-day functioning and by a minimum time period in which the symptoms are present.
Many people who suffer from PTSD can function to a certain extend in their lives but often withdraw from others, have fits of anger and are at a high risk of developing other ("comorbid") psychiatric disorders.
Treatment approaches for PTSD in Western Medicine and Psychology focus mostly on psychotherapy whereas pharmacotherapy is used often additionally. Among psychotherapeutic approaches cognitive behavioral therapies are the best studied. Treatment with these methods resulting in successful remittance of symptoms is highly probable.
Narrative Exposure Therapy (NET) is a psychotherapeutic treatment for PTSD and combines elements of cognitive behavioral approaches with testimony therapy. Its aim is to establish a coherent narration in written form of the patient's life with a specific focus on the traumatic events. Background of this approach is that traumatic memories usually are not verbally accessible but extremely fragmented and associated with extreme emotional reactions ("hot memory"). NET aims to make these memories verbally accessible (expressing the incomprehensible), to anchor the traumatic event in a meaningful time and space chronology and to modify the associated emotional reaction (please find a more extensive description of NET and background on PTSD in the 5). NET has so far been successfully applied in an ambulatory clinical setting at the University of Konstanz, Germany, and at the Center for Emotion and Attention at the University of Gainesville, USA with survivors of violence and torture from various countries and also in the `field' with victims of the Kosovo crisis, and in a Northern Ugandan camp, hosting Sudanese refugees.
4.1 Research Question
This therapy study has the aim to validate whether this form of therapy is effective and appropriate in the Somali context (acceptance by patients and culture) and whether it can be applied successfully by trained paramedic local staff.
4.2 Methodology
Design
In order to test the efficacy and applicability of a therapeutic approach, data assessment, realization of therapy and control condition have to be standardized. The design we developed for the first trial on Narrative Exposure Therapy with beneficiaries of the DRP Somaliland therefore had to follow strict guidelines. It is shown in graph 10 on the next page. First all participants took part in the pre-test, to ascertain their condition, e.g. symptoms of PTSD or depression). Then all of them were randomly assigned to either to a treatment or control protocol. Six weeks after the end of the treatment a post-test for both groups will again assess symptoms.
Participants
A small group of beneficiaries of the DRP who had been identified as having Posttraumatic Stress Disorder (PTSd) were asked to participate in this study. All gave their written informed consent before inclusion in the study. All were tested again to ascertain that they still suffer from PTSD related symptoms. This resulted in N = 14 beneficiaries with PTSD who agreed to participate in this study. Randomly they were chosen for the treatment condition (six sessions of Narrative Exposure Therapy) or control condition (waiting list).
Graph 10: Research Design of Narrative Exposure Therapy Study
Experimental Conditions
The treatment condition consisted of six sessions of Narrative Exposure Therapy. The sessions took place once or twice weekly with a duration ranging between 60 to 120 minutes. Appointments were made in the morning, afternoon or evening depending on when the participant found time. The sessions were conducted in the way described above.
The beneficiaries in the control condition did not receive any treatment session but were only subjected to the testing procedure (pre-tests and post-test).
Therapists
Two local paramedic staff were trained in Narrative Exposure Therapy. Both had several years of experience in caring for mentally disturbed persons (one is the responsible officer in charge of the caretaker project of the DRP Somaliland and has worked with families of mentally disturbed persons for years; the second is a member of the local NGO GAVO, Berbera).
Instruments
In the pre- and posttest, standardized psycho-diagnostic instruments were employed. To assess symptoms of Posttraumatic Stress Disorder (PTSD) the screening instrument, which was developed in the first vivo mission (February/March 2002), was employed; this screening instrument is a modified version of the Posttraumatic Diagnostic Scale (PDS). To assess symptoms of Depression and Anxiety the Hopkins Symptom Checklist (HSCL) was employed. Instruments had been translated, back-translated and culturally modified before.
4.3 Preliminary Results
Post-test results will only be available in January 2003. So far, only our first impression can be reported.
Narrative Exposure Therapy seems to be applicable in the Somali culture. The procedure was easily understood and accepted by `patients' and staff. As the Somali culture has a strong oral tradition, talking about traumatic events and telling one's own story proofed nothing strange to the patients.
Symptom relief seems to have been achieved in most of cases. Patients stated for example after the first sessions that since years they could sleep again without problems. All patients showed expected and typical change in behavior in the way they were able to talk about their traumatic experiences. In the beginning patients' recall was extremely fragmented, short, with gross omissions and non-linear chronology (difficulty locating the event in time and space). After a few sessions, reports started to become well structured, more detailed and coherent. This change in reporting pattern of the traumatic events is typical for this form of therapy and has been described in detail in the scientific literature. These changes reflect the occurrence of a change in memory processing as a result of the therapy. The observed changes in the narration can be interpreted as a result of "hot memories" becoming verbally accessible and the build-up of "cold memories" in the semantic memory system. This indicates that the so-called `fear network', which has formed in the brain as a result of the traumatic event is slowly dismantled. Based on these observations we are very optimistic that the post-test will show a clear reduction of posttraumatic symptoms in the treatment group.
As expected, our local staff experienced a number of challenges in conducting the therapy. Close supervision and support was extremely necessary. Our experience shows clearly that local "therapists" (being chosen from amongst the beneficiary community) have often lived through similar events as their `patients' and should therefore receive emotional as well as technical support and supervision to a higher extend than therapists who come from outside.
4.4 Discussion
At present (end of November 2002) no final results can be reported from the study on Narrative Exposure Therapy (NET) conducted during the past months in Hargeisa because the post-test will only be finalized in January 2003. Our first impressions allow for careful optimism due to the fact that we could observe the same patterns of symptom-relief and processing which we have seen in all other countries and cultures.
5. First Trial on Pharmacological Treatment
This activity could not be realized during the past vivo mission because it was not possible to find a local partner for cooperation in this issue. Nevertheless, it is recommended to conduct a study on pharmacological treatment of severely psychiatrically disturbed ex-combatants chained in their homes as a next step.
6. Specific Recommendations for the DRP Somaliland
Based on our above outlined research findings, showing that ex-combatants are disproportionally affected by severe and crippleing psychiatric illness and based on the fact that mental health service provision in Somaliland is virtually absent, we recommend the DRP to consider targeted mental health project activities in its next phase.
Our specific recommendations are two-fold:
1. Our data show clearly that mental health problems constitute a major obstacle for the reintegration of large parts of ex-combatants currently on government payroll and consequently for consolidation of the government budget. Therefore, separate additional activities are recommended to be established which can enhance the effect of the already ongoing reintegration activities (like vocational trainings, rural integration and business promotion) and increase the successful participation of mentally impaired beneficiaries.
2. In the long-term, the build-up of the mental health sector in Somaliland emerges as an important priority, answering to the various public mental health needs of the population. This effort could be pioneered with the start-up of a pilot project focused on ex-combatants, serving as a model for similar projects for the general population. The model project will only be successful if it includes continuous data-based validation that satisfies rigorous scientific standards and probes the effectiveness of the undertaken efforts. Since the DRP is limited in time and by definition does not aim to establish permanent structures, we recommend to additionally develop or from start include a mental health component in the extension of the project outside the DRP structure, enabling the pilot project to mature into a sustainable component of the future public mental heath sector in Somaliland.
6.1 Separate Additional Activities in the DRP
Standard Data Assessment
As a result of vivo's work so far, the DRP has two validated screening instruments for Posttraumatic Stress Disorder and Depression at hand which can be readily applied by trained local staff, e.g. together with the socio-economic interview. This data together with the information provided by the Ministry of Defense on the mental and/or physical impairment of the reported ex-combatant, will allow for identification of the critical group of beneficiaries, in need of special health service.
Health Section in DRP
Based on our findings (in the first project phase), it can be assumed that a significant part of the beneficiaries of the second phase of the DRP will suffer physical and/or mental illness-6.
The DRP is recommended to respond to this challenge by creating the position of a Mental Health Officer (MHO) who is responsible for both physical and mental assessments of beneficiaries. The MHO is envisaged to be heading the DRP Health Department, which is recommended to be established outside the DRP structure (e.g. inside an existing local health facility). The MHO ideally has a background in the biosciences, i.e., knows how to systematically acquire and analyse psychosocial data, is familiar with the spectrum of mental disorders and knowledge about psychotherapeutic and psychopharmacological treatment. She/he is the entrance point for all mentally or physically impaired beneficiaries. It is his/her responsibility to refer a beneficiary to adequate support and integration activities. Ideally, He/she actively participates in providing assistance to beneficiaries, e.g. psychotherapeutic interventions or pharmacological treatments.
Along with a Mental Health Officer, the project will definitely need several Psychosocial Workers, who are responsible for providing support and outreach to the families of the beneficiaries and establishing links with other involved institutions. These positions can partly be outsourced to local NGOs, like GAVO.
Training of staff
Psycho-social Intervention Modules
The DRP Health Section is recommended to realize a variety of activities for beneficiaries and their families. These activities can be grouped in different modules:
a) Outpatient psychiatric care for beneficiaries with severe mental disorders:
Outpatient psychopharmacological treatment, referrals to inpatient treatment
centers, psycho-social interventions with family and beneficiary, reintegration
activities (vocational training etc.).
b) Monitoring of critical cases: Regular visits at home and sessions with whole
family over a longer period of time (1 year), crisis interventions, development of
solutions and interventions
c) Crisis intervention: Short-term intervention (several weeks) with limited number
of visits at home/sessions with family and individual appointments, mediation
between different fractions, development of solutions and interventions.
d) Development of reintegration potentials for physically or mentally impaired
beneficiaries: The reintegration of psychiatrically impaired beneficiaries can be
extremely difficult because they might not fit easily in one of the DRP modules.
Additionally, beneficiaries themselves might not be able to take the necessary
decisions on their own. To develop an individual reintegration perspective for
them communication with the family, the beneficiary and all involved institutions
is necessary, e.g. "round table".
e) Specific psychological interventions: Treatment of disorders, like Posttraumatic
Stress Disorder, Depression, or drug related disorders in individual and group
settings.
The following three exemplary case studies try to give a description of the nature of the activities that the future DRP Health Section could be involved in:
a) A severely psychiatrically impaired beneficiary with psychotic symptoms:
Beneficiary is reported as mentally impaired by the Ministry of Defence. The first
assessment by the Health Officer would probably take place in the beneficiary's
home or at another place where he/she is kept (e.g. chained).
b) Beneficiary with Posttraumatic Stress Disorder and aggressive outbreaks:
Patient is identified by standard tests. The MHO provides him/her with
information of his/her condition and offers to her/him psychotherapeutic
treatment, which will be carried out by herself/himself or by one of the
Psychosocial Workers, who received adequate training. Since this group of
beneficiaries is especially vulnerable to drop-out during the reintegration process,
(e.g. due to imprisonments being a consequence of aggressive outbreaks, due to
vulnerability for deterioration of symptoms e.g. as a consequence of stressful life
events or due to excessive drug intake), close monitoring of these beneficiaries is
required and short-term interventions have to be planned for, between family,
beneficiary and other institutions. Expected remission of PTSD symptoms and
behavioural adaptation will support the successful reintegration process. A stable
income in the future as a result, will have a positive effect on the overall wellbeing
and recovery of the beneficiary and his/her family.
c) Beneficiary with physical disease or impairment:
Reported by the Ministry of Defence or reported by the DRP staff during the DRP
activities. This beneficiary suffers from long lasting consequences of his war
participation, e.g. missing limb, or from an acute disease, e.g. syphilis. Both
constitute a severe obstacle for reintegration. The Health Officer examines the
beneficiary and decides which treatment or rehabilitation approach should be
followed. A referral to specialized institutions, e.g. workshop for artificial limbs,
monitored drug treatment. Only after restoring functioning a participation in
reintegration activities start.
Services for caretakers, families and the community
A considerable part of the work of the DRP Health Section is the provision of services to caretakers and families of beneficiaries. Support, information and education about mental and physical diseases as well as best ways of handling and treatment is necessary. Families should be involved as close as possible in the treatment and demobilization activities for mentally and physically impaired beneficiaries in order to enhance the success and sustainability.
Case report
In this short chapter we provide the reader with a case report. This example shows that psychosocial activities can enhance the effects of traditional demobilization and reintegration activities.
We report here a male beneficiary, between 30 and 35 years of age and not married. He received eight years of formal education and currently lives in his parents' house. His family background can be classified as middle class with a regular income and strong religious tendencies. After joining the SNM he participated in the liberation war from 1986 to 1991. Several times he was wounded in combat and lost one leg when a mine exploded under his car. Since several years he uses an artificial limb, which enables him to walk and even drive. Since the formation of the Somaliland armed forces he was on the government payroll but did not actively serve in the army due to his handicap. Until September 2002 he owned a car and worked occasionally as a driver for one of the local governments in Hargeisa. In the past years there were severe conflicts between him, his father and his brother, mostly because of his way of life with excessive khat chewing, lack of motivation to work regularly and aggressive outbreaks. Several times he was imprisoned during the last years because of minor offences.
He was originally thought to receive his DRP benefits within the micro-credit scheme, later he was transferred to the SME department (Small and Micro Enterprises). But he changed his mind several times about how to use the grant and therefore it was not possible to elaborate a project with him. Until the beginning of November 2002 he had not received any benefits and was not demobilized. He was detected as being mentally obtrusive in the psychological screening during the vivo mission in February and March 2002 with symptoms of psychological trauma (PTSD), excessive khat consumption, and extreme paranoid believes but also sleeping and concentration problems. In respect to every day functioning he can be considered severely impaired: withdrawal from almost all social contacts, did not manage to work regularly. He was invited to participate in our therapy study in October and November 2002.
In September 2002 his situation deteriorated significantly after he had been involved in a traffic accident, a consequence of which was the total destruction of his car. Since then he committed himself more than before to excessive khat chewing and displayed several times aggressive outbreaks against family members. Because of throwing a petroleum lamp at his brother, his family agreed to send him to prison - a common practice in Somaliland. He was brought immediately to the local police station where he was kept in a cell while his father applied for his transference to a state prison. A judge can order a psychiatric patient for a maximum of three months to a state prison. This was detected because the beneficiary did not appear to several treatment sessions.
In short, his situation in November 2002 can be summarized as being in danger of losing his chance of reintegration because being about to be sent to prison for the rest of the project terms.
For this reason we initiated a psycho-social intervention to prevent a negative outcome. The intervention consisted of the following activities:
- Visit of the beneficiary's home, exploration of the problem and explaining the view of the DRP to the family.
- Mediation between family, police and beneficiary.
- Development of a reintegration perspective together with family, beneficiary and DRP.
- Initiating monitoring and care for the beneficiary (one session in individual or family setting with a trained counselor)
The consequences of these activities were:
- The family agreed to liberate him.
- He could participate in the psychotherapeutic treatment.
- A proposal for a small business (buying a car to enable his work as a driver) was
elaborated in meetings with father, mother, beneficiary, SME officer and vivo team
member. The family was actively involved in the reintegration perspective (paying
for half of the car). The benefits were transferred within few weeks and he was
successfully demobilized.
- A specially trained Somaliland medical expert was contracted to monitor and
counsel him for several months.
6.2 Participation in Building up the Mental Health Sector
Cooperation with, Contracting of and Capacity Building of Local Institutions Ideally, the DRP Health section should be piloted as a model for community mental health centers all over Somaliland. Therefore, it is recommended that the DRP
Health Section is situated inside an existing local health institution and is transferred to the public health sector during the project phase. Also local experience and expertise, e.g. information gathering, meetings, should be mobilized for contribution towards the new mental health outreach sector.
It is recommended to continuously outsource parts of the DRP mental health activities so that finally services provision could be shared with local NGOs like GAVO, e.g contracting GAVO for provision of social worker services for the DRP. Inpatient treatment centers can also be contracted to provide part of the services, e.g. inpatient psychopharmacological treatment for severe cases.
Cooperating local institutions should be systematically included in capacity building activities, like trainings for staff, rehabilitation or rent of buildings or short-term consultancies. Capacity building of local institutions should be a crucial part of the DRP Health Section activities.
6.3 Evaluation of Activities and Further Studies
In the view of the pioneering character of the recommended psycho-social activities the DRP Health Section should be constantly involved in evaluation activities and scientific studies. These aim to provide quantitative and qualitative data to decision makers in order to estimate the effect of the undertaken measures. The specifics of Somaliland make it ideal for a scientific program to develop new tools and new ways in the field of demobilization and reintegration of ex-combatants that can be later on transferred to neighboring regions (Southern Somalia, Ethiopia, Sudan). For that reasons we recommend two directions of research activities:
Evaluation of the activities of the DRP health Section
It is strongly recommended to systematically evaluate the outcome of the DRP Mental Health Section, for example: the effect of the different psychosocial activities on the successful reintegration, the sustainability of income and about well being of beneficiaries (follow up), comparison with control groups, or analyzing factors that improve or reduce the probability of successful reintegration. A very important part of scientific work in the DRP Health Section would be the development and evaluation of an adequate drug rehabilitation program. Treatment procedures how to help addicts to break the vicious circle of dependence have to be adjusted to the Somaliland conditions and to the particular type of drug - in this case khat.
Further studies
Continuing the work already started, further studies are recommended in order to better understand the situation of ex-combatants and civilian war survivors and to generate knowledge and research designs that can be of use for the extension of EC's work in the region. Further studies that are recommended are:
- Assessment of the magnitude of the khat consumption in whole Somaliland and
the comparison between urban and rural areas, between ex-combatants and
civilian war survivors, and between the adolescent and the adult population.
- Assessment of prevalence of psychiatric disorders in the whole country and the
comparison between urban and rural areas, between ex-combatants and civilian
war survivors and the economic and emotional burden for the caretakers.
- Quantitative and qualitative assessment of the changes in the khat consuming
habits during the last decades. It is very obvious that the current way of khat
consumption differs substantially from the traditional habits of its use (friends or
business partners gather for a "khat party"). But the current scientific literature
does not systematically reflect the current situation, but provides sporadic
descriptions about the changes that occurred (e.g. personal impressions). Main
publications and knowledge of decision makers still rely on information gathered
more than a decade ago.
This vast need for systematic work outlined here cannot be realized by or financed within a Demobilization and Reintegration Project.
7. General Recommendations
7.1 Health Sector
Establishing Community-Based Mental Health Services
Mental health services in Western countries traditionally were offered in centralized institutions, like mental hospitals. In the seventies an alternative movement of psychiatry started to decentralize mental health services. "Back to the community" was the slogan and it meant that services were offered in proximity to the place of residence, often in form of outpatient services, that enabled the patient to stay within the family while receiving treatment. Such services were provided over a long period of time by the same institutions and took into account the every-day problems of the patient. This model is now acknowledged and endorsed by WHO, especially referring to underdeveloped countries (World Health Report 2001).
In Somaliland, mental health services are traditionally delivered by healers and sheiks, who live in and with the community. But the recent decades also brought the construction of centralized mental hospitals in Hargeisa and Berbera, partially funded through aid coming from abroad. No medical doctor however works currently in the mental ward of the Hargeisa Group Hospital and most of the 10 staff members who care for about 100 patients have no qualification at all, partly being former patients themselves. This is no wonder taking into consideration the extremely low salary of approximately 60 US$ per month for a medical doctor which does not enable a decent living. Treatment constitutes basically of chaining patients and providing a cocktail of psychopharmacological drugs. While the situation in the second mental hospital in Berbera must have looked the same some years ago, the last five years brought a significant change: The Italian NGOs GRT (Milano) and COOPI committed themselves to improving the situation. Especially GRT who works directly in the mental hospital follows a community-based framework. This means, GRT provides only a part of the expenses and tries to involve the community in covering the running costs, trains and educates the staff and creates awareness among the population. This lead to a remarkable success - the mental health services in Berbera work independently of foreign aid.
As a consequence, a six months break of financial flow-in 2001/2002 did not lead to a break down of service in the Mental Hospital, in contrast to the General Hospital Berbera where COOPI had not followe the community-based ideas in the same consistent manner. Furthermore, in the case of Berbera, existing local initiatives were encouraged and supported by trainings, covering part of the running costs. Another excellent example of community-based mental health work is the Berbera youth organization GAVO, which started some years after the war with providing care for mentally disturbed persons living on the streets. GRT trained GAVO members and enabled them to establish an outpatient treatment center for mentally impaired persons and their caretakers. The community could be involved to a considerable degree to cover running costs, e.g. the municipality covers the costs for a teacher. Currently GAVO tries to expand their activities to neighboring towns relying mostly on the help of private persons, fundraising through communities abroad and public funds.
The Berbera experience can be considered a good example of how to improve the mental health sector in Somaliland in a sustainable way overall.
We therefore recommend community-based outpatient treatment centers for mentally impaired persons and their caretakers to be established all over the country. These centers should not only provide pharmacological treatment to patients, but also a much wider range of services, like drug rehabilitation and general reintegration support, including vocational training. Caretakers and families of mentally impaired persons should equally find support and help in these centers. Finally, these centers should carry out manifold awareness raising activities like e.g. information on the implication of khat-chewing for children and pregnant/breastfeeding mothers.
Mental Hospitals
Nevertheless, inpatient treatment centers should be the second and equally important pillar of the future mental health sector. At present these inpatient treatment centers are not equipped to work properly. The reasons are abundant, starting from lack of even basic resources (e.g. gloves, medication) to absence of training for staff members. The first step that should be undertaken is to improve the working conditions of these institutions to the end that they can provide qualified services. Training of staff, recruitment of additional personnel, mobilization of sustainable financial resources, rehabilitation of buildings, and provision of the required psychopharmacological drugs are essential steps.
Awareness raising
Our work in Somaliland has shown that knowledge about mental health and
awareness of risk factors only sporadically exists among the population. Although
khat is perceived as a dangerous drug by a growing proportion of the population the
vast majority still sees it as a harmless or even positive stimulant. Additionally,
among large parts of the population traditionally existing rules restricting khat
intake disappear, like the cultural restriction of khat intake by children and women.
In the Borama region (main khat growing region of Somalilan
d) the rural population
finds it nowadays adequate that children older than eight years of age chew khat
(personal communication with Analena Tonelli, WHO Borama).
This shows clearly that adequate knowledge about the implications and effects of khat consumption is absent. Institutions like the Ministry of Health with the support of WHO and other international and local organizations, should certainly engage in a multi-sectoral, well coordinated awareness raising campaign. It is strongly recommended to create a task force to bring together various agencies in order to coordinate the awareness creating activities in Somaliland, so that all activities are based on a common plan and understanding.
It is further recommended to use the radio as the preferred media for awareness creation because large parts of the population are illiterate and do not have access to other kind of media. First efforts have already been initiated by GRT/COOPI in Berbera.
We recommend that such activities be realized as a separate project with independent funding, but in close collaboration to the work of the taskforce. Despite all inherent dangers, we acknowledge that khat is part of the cultural identity of Somaliland and we recognize that it has strong affiliations to the recent history. Therefore, raising awareness of its dangers and simultaneously attempting to reintroduce the traditional restrictions of its use (e.g. not in the morning and not for children) seems to be the best way to address this problem politically.
7.2 Economic Recommendations
The khat business constitutes a considerable part of the total economic activity in Somaliland. Hundreds of small sellers crowd the streets, among them many women. For petty business khat seems to be very attractive because of its simplicity: as no storage of the traded good is possible or necessary, the seller buys khat several times a day from the central khat market. The product needs to be put on the market fast, so many small traders are welcome middle-men. On the macro-economic level, the government earns a considerable part of its revenue through taxes put on khat. In the Western part of the country, khat cultivation is becoming an increasingly important economic factor, enabling a far better income for small farmers compared to growing sorghum or maize.
Assessment of economic consequences of khat intake
Whether khat is a benefit or a disadvantage for the Somaliland economy has not been researched adequately at this stage. On one hand its immediate short-term economic importance is obvious, on the other hand the social and economic longterm consequences (hidden costs) for society seem devastating: less money available for food, education, and health care at the micro-economic level (household, community) and less investments on the macro-economic level (as money transferred to Somaliland is retransferred out of the country again, e.g. to khat producing regions in Ethiopia), as well as the direct and indirect costs for care or loss of income as a consequence of khat induced physical and mental illnesses, including the tremendous losses due to the breakup of social fabric and impairment of children's healthy development.
We suggest that this question should be addressed by an independent economic assessment exercise that comes up with an estimate and a projection of economic as well as social gains and losses for Somaliland due to khat consumption for the next decades. This would certainly enable all involved parties in the current debate on khat in Somaliland to better understand the situation and find adequate measures to address the problem. It can already be predicted that the development of income generating strategies alternative to khat e.g. training in business skills or introduction of other cash crops by which a considerable income can be guaranteed to farmers, will be an important issue in the future.
NOTES
1 The more recent satellite image of Hargeisa could not be used because of its special properties.
2 We prefer to call them "person with severe mental disorder" but we also use the term "mental case"
for it is shorter.
3 The term "schizophrenia spectrum disorder" refers to a group of psychiatric disorders, with
common schizophrenic symptoms lasting for one month or more. Typical symptoms are paranoia,
hallucinations, thought disorders, negative symptoms etc. Disorders which belong to this category for
example are: Schizophrenia, Schizotypic and Delusional Disorders (ICD 10 F20 - F29), Psychic and
Conduct Disorders caused by Psychotropic Drugs (ICD 10 F10 - F19), Psychic Disorders caused by
Organic Diseases (ICD 10 F06).
4 The terms "khat induced psychosis" and "khat psychosis" are used to indicate that the psychosis
with excessive khat abuse before the onset of symptoms is a specific type of schizophrenia-like
disorder, which is related to and triggered by khat abuse. We compare it with the so-called
"amphetamine psychosis", a disorder which is triggered by amphetamine abuse and has
schizophrenia-like symptoms.
5 Please find in the Bibliography of this report some references to publications concerning NET, e.g. Neuner, F., Schauer, M., Elbert, T. & Roth, W.T. (2002), A narrative exposure treatment as intervention in a refugee camp: a case report, Behavioural and Cognitive Psychotherapy, 30, 205-209
6 The Ministry of Defense already submitted a first draft of a list of beneficiaries for the extended DRP.
According to that information about 40% of the so far reported ex-combatants have some form of physical or mental impairment. Based on our previous findings one can expect that an additional 30% of ex-combatants, which are actually reported as healthy also have some form of psychiatric disorder, mostly Posttraumatic Stress Disorder and Depression. Training can partly be provided during ongoing work, e.g. in form of short seminars or through short-term consultancies, e.g. expert visits, within the
project. It is recommended to establish a curriculum for a training course, which can
be repeated regularly for new staff and members of contracted local NGOs.
8. Bibliography
Clark, D. A. (2002). Interagency Returnee Settlement Area Assessment - Informational Report. Hargeisa:
CARE, DRC, FSAU, HI, ICD, IRC, Save/US, UNDP, UNHCR, and UNICEF.
Covington, H.E. & Miczek, K.A. (2001). Repeated social-defeat stress, cocaine and morphine: Effects on
behavioral sensitization and intravenous cocaine self-administration "binges".
Psychopharmacology (Berl.), 158, 388-398
Crombag, H.S., Badiani, A., Chan, J., Dell'Orco, J., Dineen, S.P., & Robinson, T.E. (2001). The ability of
environmental context to facilitate psychomotor sensitization to amphetamine can be dissociated
from its effect on acute drug responsiveness and on conditioned responding.
Neuropsychopharmacology, 24, 680-690
Elbert, T. & Schauer, M. (2002), Burnt into Memory, NATURE, Vol 419, 883
Ellinwood, E.H., Sudilovsky, A., & Nelson, L.M. (1973). Evolving behavior in the clinical and experimental
amphetamine (model) psychosis. American Journal of Psychiatry, 130, 1088-1093
Ellison, G.D. & Eison, M.S. (1983). Continuous amphetamine intoxication: an animal model of the acute
psychotic episode. Psychological Medicine, 13, 751-761
Goeders, N. (2002). Stress and cocaine addiction. Journal of Pharmacology and Experimental Therapeutics,
301, 785-789
Griffith, J.D., Cavanaugh, J., Held, J., & Oates, J.A. (1972). Dextroamphetamine: Evaluation of psychomimetic
properties in man. Archives of General Psychiatry, 26, 97-100
Karunakara, U., Neuner, F., Schauer, M., Singh, K., Elbert, T., Burnham G. (2002). Forced migration and
post traumatic stress: prevalence and predictors of PTSD in the Sudanese and Ugandan populations
in the West Nile, in preparation
Neuner, F., Schauer, M., Elbert, T. & Roth, W.T. (2002), A narrative exposure treatment as intervention in a
refugee camp: a case report, Behavioural and Cognitive Psychotherapy, 30, 205-209
Odenwald, M., Schauer, M., Lingenfelder, B. & Elbert, T. (2002). Vivo mission report EC/GTZ
Demobilization and Reintegration Program in Somaliland. Hargeisa, Nairobi: GTZ and
European Community
Roninson, T.E., Browman, K.E., Crombag, H.S. & Badiani, A. (1998). Modulation of the induction or
expression of psychostimulant sensitization by circumstances surrounding drug administration.
Neuroscience & Biobehavioral Reviews, 22, 347-354
Schauer, M., Kluttig, T., Elbert, T., Junghoefer, M., Neuner, F., Hoffmann, K. & Rockstroh, B. (2002).
Trauma & Delinquency: Psychophysiological Evidence for the Dysregulation of Affect in
Traumatized Forensic Patients. Psychophysiology, Vol. 39, S75
Sato, M. (1992). A lasting vulnerability to psychosis in patients with previous methamphetamine psychosis.
Annals of the New York Academy of Science, Vol. 654, 160-170
World Health Organization. The World Health Report: 2001: Mental Health: New Understanding, New
Hope. Geneva: WHO, 2001
Yui, K., Goto, K., Ikemoto, S., Ishiguro, T., Angrist, B., Duncan, G.E., Sheitman, B.B., Lieberman, J.A.,
Bracha, S.H., & Ali, S.F. (1999). Neurobiological basis of relapse prediction in stimulantinduced
psychosis and schizophrenia: the role of sensitization. Molecular Psychiatry, 4, 512-523
Appendix
A. Screening Instrument
B. Curriculum for Training of Staff
Appendix A: Instruments
Wareysiga Ibidimooloojiyada
Epidemiologic Interview
Magaca Waraystaha: ________________________________________________________________
Name of interviewer
Taariikhda: ______________ Wakhtiga: ______________ Mudada Waraysiga: ______________
Date Time Duration of interview
Halka uu deggan yahay: ______________________________________________________________
Location of home ______________________________________________________________
Wareysiga lala yeelanayo madaxa qoyska:
Interview with head of the household
Magaca madaxa qoyska: ______________________________________________________________
Name of household head
1 Ma Joogaa Madaxa Qoysku? / Is the household head available? q haa q maya
2 HADDII AY TAHAY MAYA (1) / IF NO ON (1)
Magaca La Wareystaha / Name of interviewee: _______________________________________________________
Xidhiidhka ka Dhexeeya MadaxQoyska / Relationship towards household head: ______________________________
3 Gabi ahaan immisa qof ayaa ku nool gurigiina? / How many persons are there in total living in your household?
No.:
Tirada:
4 Intee jeer ayaa cuntada guriga lagu kariyo ayuu ku jiraa hilib? /
How often do meals in your household include any (big piece of) meat?
READ ALL ANSWERS (and select one)!!V
AKHRI JAWAABAHA OO DHAN (oo dooro mid)!!
q Maalin kasta (every day)
q Mar in ka badan usbuuci (more than once per week)
q Hal mar ama ka yar usbuucii (once per week or less)
q Hal mar bishii (once per month)
q Mar in ka yar bishii (less than once per month)
q Lama garanayo (not known)
5 Gurigiinu laydh ma leeyahay? / Do you have electrical power in your house? q haa q maya
6 Gurigiinu Biyo Socda ma leeyahay? / Do you have running water in your house? q haa q maya
7 Gurigiinu Telefishan ma leeyahay? / Do you have a television in your household? q haa q maya
8 Gurigiinu Gaadhi ma leeyahay? / Does your household own a car? q haa q maya
9 FADLAN QIYAAS / PLEASE RATE:
Qoyska ma wuxuu ku nool yahay ./ Does the family live in a.
q Buul (Alaabo kal
e) / hut
q Guri Dhagax ah (Dhagax/ Sibidh) / house
q Bangalo Deyr leh / compound
10 FADLAN QIYAAS / PLEASE RATE:
Dakhliga gurigu ma . Is the income of the household.
q Aad u hosseeya very low
q Hooseeya low
q Dhexdhexaad medium
q Sareeya high
q Aad u sareeya very high
PART TWO
Wareysiga lala yeelanayo madaxa qoyska / Interview with head of the household
11 Iminka waxaan jecelahay in aan ku waydiiyo su'aalo ku saabsan xubnaha qoyskaaga. Ma ii sheegi kartaa magacyada xubnaha qoyskaagaa? / Now I would like to ask you some questions about all members of your household. Can you tell me the names of every member of your household?
FADLAN WAXAAD SHAXDAN KU LIFAAQAN GELISAA MAGACYADA QOYSKA OO DHAN, KUNA
MUUJISAA JINSIGOODA.
PLEASE FILL IN ALL NAMES IN THE TABLE BELOW AND MARK THE GENDER IN THE COLUMN BESIDE.
12 Ma jiraan dad qoyskiina ka tirsanaa oo aan hadda joogin sababta oo ah iyagoo xidhan, hoy la'aan ama Isbitaalka caadiga ah iyo ka waalida ah,daawo dhaqameed,sheekh ama ku nool meel kale oo dibadda ka ah guriga? / Are there persons who once belonged to your household, but are not around anymore, because they are imprisoned, homeless, in hospital, mental hospital, at a traditional healer/sheik or living outside house/at other place?
HADDII AY JAWAABTU HAA TAHAY, MAGACYADA DADKAAS KU BUUXI SHAXDA LIFAAQA AH, KUNA CALAAMIDI TIRADA LA XIDHIIDHA EE KHAANADA BIDIX EE SHAXDA.
IF YES, FILL IN THESE NAMES AS WELL IN THE TABLE AND MARK THE RELATED NUMBER IN THE LEFT COLUMN BESIDE.
SU'AALAHAN WEYDII QOFKA KASTA OO GURIGA KA MID AH (OO UU KU JIRA MADAXA
QOYSKU) KUNA BUUXI JAWAABAHA SHAXDA LIFAAQA AH.
ASK THE FOLLOWING QUESTIONS ABOUT EVERY PERSON OF THE HOUSEHOLD (INCLUDING HOUSEHOLD HEA
d) AND FILL IN THE ANSWERS IN THE TABLE BELOW:
13 Waa imisa jir. (Magaca 1, 2, 3.)? / How old is.(name 1, 2,3.)?
14 Xaalad xaaseedka? / What is his/her marital status?
15 Imisa sannadood ayuu/ayey tegi jirey/jirtay iskuul oo aanay ku jirin malcaamad quraanku? / How many
years did he/she go to school excluding Koranic school?
16 Waa maxay shaqadoodu isaga/iyada? / What is his/her occupation?
17 Imisa mijood oo qaad ayuu/ayey cuney/tey toddobaadkii hore? How many bundles of khat did he/she chew last week?
18 Ma qiyaasi kartaa qiimaha uu ku joogey qaadkaasi isaga/iyada? / How much money did he/she spend on khat last week (in dollar)?
19 Ma ka qaybgalay/ka qaybgeshay dagaal hubeysan? / Has he/she been fighting in combat?
20 Miyuu/yey goob-joog u ahaa/ahayd ama soo aragtey xaalad aad u adag intii dagaalka hubeysani uu
socdey? / Has he/she witnessed or experienced extremely stressful events during the war as a civilian?
21 Hadda waxaan jeclaan lahaa in aan ku weydiiyo inay jiraan in dad ka mid ah qoysku oo qaba cudurka dhimirka kuwaasoo aad u ba'an oo ka saameeyey qofka Masruufka ama dakhliga keena ama caawimada reerka qoyska in ka badan afartii toddobaad ee u dambeeyey? / Now I would like to ask you if there are any members of your household who currently have mental problems that are so severe that they affect the person in providing income or helping in the household for at least four weeks?
KU CALAAMIDI HAA AMA MAYA KHAANADA DHIBAATOOYINKA LA XIDHIIDHA CUDURKA
DHIMIRKA SAFKA LA XIDHIIDHA MAGACA.
QOF KASTA OO QOYSKA KA MID AH KA BUUXI SU'AALAHAN KU QORAN XAASHIDA SU'AALAHA LABAAD.
PLEASE MARK YES OR NO IN THE COLUMN FOR CURRENT MENTAL PROBLEM IN THE ROW FOR THE RELATED NAME. FOR EVERY PERSON FILL IN QUESTIONNAIRE 2.
22 Ma jiraan cid kale oo qoyska ka mid ah oo qaba dhibaatooyinka xagga dhimirka ah wakhti hore ugu yaraan lix bilood, kuwaasoo si ba'an, u saameeyey qoka soo saari jirey dakhli ama caawimada qoyska?
Are there any other members of your household who had mental problems in the past for at least six months that were so severe that they affected the person in providing income or helping in the household?
FADLAN KU CALAAMADI HAA AMA MAYA KHAANADA DHIBAATOOYINKA LA XIDHIIDHA
CUDURKA DHIMIRKA EE HORE SAFKA LA XIDHIIDHA MAGACA.
QOFKA KASTA OO KA MID AH QOYSKA KA BUUXI SU'AALAHAN KU QORAN XAASHIDA
SU'AALAHA LABAAD.
PLEASE MARK YES OR NO IN THE COLUMN FOR MENTAL PROBLEMS IN THE PAST IN THE ROW FOR THE RELATED NAME.
FOR EVERY PERSON FILL IN QUESTIONNAIRE 2.