Mental health in Nicaragua : with special reference to psychological trauma and suicidal behaviour

This thesis explores mental health problems relating to war and natural disaster and suicidal behaviour in the Nicaraguan population. The more specific aims of the study were to assess the prevalence and sociodemographic correlates of mental disorder in a community-based study during time of war (Paper I), to assess the mental health impact of Hurricane Mitch in 1998 (Paper II), to assess the incidence of hospitalized parasuicide cases and groups at risk (Paper III), and to examine suicide intent among attempters relating to gender, suicide method and sociodemographic factors and identify predictors for repetition of an attempt (Paper IV). Method: Based on 4453 family food ration books for families living in an urban area of León, Subtiava, 219 families including 746 adults were selected through a systematic sampling procedure. The study was conducted in 1987 during the war. We were able to reach 584 adults for interview according to the Present State Examination for ICD-9 diagnoses and Self-Report Questionnaire (Paper I). In Paper II, 496 adult primary health care attendees were interviewed six months after Hurricane Mitch according to the Harvard Trauma Questionnaire and were diagnosed for post-traumatic stress disorder (PTSD) according to DSM-IV. In Papers III and IV, all cases from León city admitted to HEODRA Hospital for a suicide attempt over a three-year period (n=233) were interviewed regarding sociodemographic factors and method, time and place of the suicide attempt. A subgroup of 204 cases was interviewed using the Suicide Intent Scale (SIS). Out of those 106 cases were followed-up regarding repetition of attempt or completed suicide after a mean period of 1172 days. Results: In the Paper I study, the one-month prevalence of any mental disorder was 28.8% for men and 30.8% for women. Among men, alcoholism was the most common diagnosis, whereas neurosis, crisis reaction and depression were dominant among women. Alcoholism was scored as the second most severe disorder after psychosis in terms of functional level. In the Mitch study six months after the hurricane, traumatic events were common and 39% reported death or serious injury of a close relative as a result of the hurricane. The prevalence of PTSD ranged from 4.5% in the least damaged area to 9.0% in the worst damaged area. At the prolonged follow-up six months later, half of the cases still retained their diagnosis. Trauma-related symptoms were common and death of a relative, destroyed house, female sex, illiteracy and previous mental health problems were associated with a higher level of symptoms. Suicidal ideation was reported among 8.5% and was significantly associated with previous mental health problems and illiteracy. The studies regarding hospitalized parasuicides showed the highest rate among girls aged 15–19 years (302 attempts per 100 000 inhabitants and year). After drug intoxication, pesticide was the second most common method and most often used by men (23%). Half of the women had recent contact with health care services before attempting suicide. There were significant peaks regarding time of attempt in terms of seasonal and diurnal distribution. Overall scores regarding seriousness of the intent (SIS) were equal between the sexes, but the pattern of SIS items showed significant gender differences in terms of relation to background factors and method used. For women, having a child was one factor associated with higher seriousness. Factor analysis of SIS items revealed a four-factor solution, explaining 59% of the variance. Risk for fatal repetition was 3.2% after three years and for non-fatal repetition 4.8%. During follow-up, three men (11%) had completed suicide but no women. We failed to identify any predictors for repetition from background factors or SIS. Conclusion: The studies have identified different groups at risk for mental health problems relating to war and disasters. Parasuicide rates equalled those from European countries. Whereas young girls dominated, attempts among men were more severe in terms of the methods used and completed suicide at follow-up. SIS seemed to give a meaningful pattern among women but not for men. In our study, seriousness of attempt in terms of method or suicide intent did not predict repetition. Overall non-fatal repetition rate was very low as compared to other studies