Trauma exposure, depression, suicidal ideation, and alcohol use in people with severe mental disorder in Ethiopia
To investigate exposure to traumatic and stressful events and their association with depression, suicidal ideation, and alcohol abuse in people with severe mental disorder (SMD) in Ethiopia.
As part of the Programme for Improving Mental health carE, 300 people with SMD (84% primary psychosis, 11% bipolar disorder, and 16% depression with psychotic features) in a rural district were identified by psychiatric nurses. A cross-sectional assessment included clinical characteristics, experience of being restrained, exposure to stressful events as measured by an adapted version of the List of Threatening Experiences scale, traumatic events as measured by endorsement of 13 locally relevant potentially traumatic events that occurred since the onset of the participant’s mental illness, depression symptoms measured by the Patient Health Questionnaire, the Suicidal Behavior Module of the Composite International Diagnostic Interview, and hazardous drinking which was calculated as a sum score of eight or higher on the Alcohol Use Disorders Identification Test.
Almost half of participants reported being restrained since becoming ill, which was associated with more suicidal ideation and less hazardous drinking. More than one-third experienced traumatic events since becoming ill, including being assaulted, beaten, or raped. Exposure to traumatic events was associated with hazardous drinking.
In this rural Ethiopian setting, people with SMD experienced high levels of traumatic and stressful events which were associated with co-morbid conditions. Greater attention needs to be given to trauma prevention and integration of treatment for trauma sequelae in efforts to expand integrated mental health care.
KeywordsAlcoholism Depression Psychotic disorders Life change events Post-traumatic
This study is a direct output of the PRogramme for Improving Mental health carE (PRIME). This work was supported by the UK Department for International Development (201446). The views expressed do not necessarily reflect the UK Government’s official policies. LN’s time was funded by the National Institute of Mental Health (NIMH) Grant numbers #T32MH093310 and #K23MH110601. The funders had no role in data collection, analysis, writing, or decision to submit the article for publication.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no competing interests.
The study was approved by the Institutional Review Board of the College of Health Sciences of Addis Ababa University. The secondary analyses presented here were reviewed by the Boston University Medical Campus Institutional Review Board and were determined to not be human subjects’ research.
All participants gave informed consent to participate.
- 2.Goodman LA, Salyers MP, Mueser KT, Rosenberg SD, Swartz M, Essock SM, Osher FC, Butterfield MI, Swanson J (2001) Recent victimization in women and men with severe mental illness: prevalence and correlates. J Trauma Stress 14(4):615–632. https://doi.org/10.1023/a:1013026318450 CrossRefPubMedGoogle Scholar
- 6.Bajor LA, Lai Z, Goodrich DE, Miller CJ, Penfold RB, Myra Kim H, Bauer MS, Kilbourne AM (2013) Posttraumatic stress disorder, depression, and health-related quality of life in patients with bipolar disorder: review and new data from a multi-site community clinic sample. J Affect Disord 145(2):232–239. https://doi.org/10.1016/j.jad.2012.08.005 CrossRefPubMedGoogle Scholar
- 7.Heins M, Simons C, Lataster T, Pfeifer S, Versmissen D, Lardinois M, Marcelis M, Delespaul P, Krabbendam L, van Os J, Myin-Germeys I (2011) Childhood trauma and psychosis: a case–control and case-sibling comparison across different levels of genetic liability, psychopathology, and type of trauma. Am J Psychiatry 168(12):1286–1294. https://doi.org/10.1176/appi.ajp.2011.10101531 CrossRefPubMedGoogle Scholar
- 8.Kelleher I, Keeley H, Corcoran P, Ramsay H, Wasserman C, Carli V, Sarchiapone M, Hoven C, Wasserman D, Cannon M (2013) Childhood trauma and psychosis in a prospective cohort study: cause, effect, and directionality. Am J Psychiatry 170(7):734–741. https://doi.org/10.1176/appi.ajp.2012.12091169 CrossRefPubMedGoogle Scholar
- 9.Varese F, Smeets F, Drukker M, Lieverse R, Lataster T, Viechtbauer W, Read J, van Os J, Bentall RP (2012) Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull 38(4):661–671. https://doi.org/10.1093/schbul/sbs050 CrossRefPubMedCentralPubMedGoogle Scholar
- 11.Ramsay CE, Flanagan P, Gantt S, Broussard B, Compton MT (2011) Clinical correlates of maltreatment and traumatic experiences in childhood and adolescence among predominantly African American, socially disadvantaged, hospitalized, first-episode psychosis patients. Psychiatry Res 188(3):343–349. https://doi.org/10.1016/j.psychres.2011.05.019 CrossRefPubMedCentralPubMedGoogle Scholar
- 17.Ventevogel P, Ndayisaba H, van de Put W (2011) Psychosocial assistance and decentralised mental health care in post conflict Burundi 2000–2008. Intervention 9(3):315–331Google Scholar
- 18.Kane JC, Ventevogel P, Spiegel P, Bass JK, van Ommeren M, Tol WA (2014) Mental, neurological, and substance use problems among refugees in primary health care: analysis of the Health Information System in 90 refugee camps. BMC Med 12:228. https://doi.org/10.1186/s12916-014-0228-9 CrossRefPubMedCentralPubMedGoogle Scholar
- 19.Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, Bruffaerts R, de Girolamo G, de Graaf R, Gureje O, Haro JM, Karam EG, Kessler RC, Kovess V, Lane MC, Lee S, Levinson D, Ono Y, Petukhova M, Posada-Villa J, Seedat S, Wells JE (2007) Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370(9590):841–850. https://doi.org/10.1016/s0140-6736(07)61414-7 CrossRefPubMedCentralPubMedGoogle Scholar
- 23.Girma E, Tesfaye M, Froeschl G, Moller-Leimkuhler AM, Dehning S, Muller N (2013) Facility based cross-sectional study of self stigma among people with mental illness: towards patient empowerment approach. Int J Ment Health Syst 7(1):21. https://doi.org/10.1186/1752-4458-7-21 CrossRefPubMedCentralPubMedGoogle Scholar
- 24.Girma E, Moller-Leimkuhler AM, Muller N, Dehning S, Froeschl G, Tesfaye M (2014) Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia. BMC Int Health Hum Rights 14:2. https://doi.org/10.1186/1472-698x-14-2 CrossRefPubMedCentralPubMedGoogle Scholar
- 25.Girma E, Tesfaye M, Froeschl G, Moller-Leimkuhler AM, Muller N, Dehning S (2013) Public stigma against people with mental illness in the Gilgel Gibe Field Research Center (GGFRC) in Southwest Ethiopia. PLoS One 8(12):e82116. https://doi.org/10.1371/journal.pone.0082116 CrossRefPubMedCentralPubMedGoogle Scholar
- 28.Shibre T, Negash A, Kullgren G, Kebede D, Alem A, Fekadu A, Fekadu D, Madhin G, Jacobsson L (2001) Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Soc Psychiatry Psychiatr Epidemiol 36(6):299–303CrossRefPubMedGoogle Scholar
- 29.Shibre T, Kebede D, Alem A, Negash A, Deyassa N, Fekadu A, Fekadu D, Jacobsson L, Kullgren G (2003) Schizophrenia: illness impact on family members in a traditional society–rural Ethiopia. Soc Psychiatry Psychiatr Epidemiol 38(1):27–34. https://doi.org/10.1007/s00127-003-0594-7 CrossRefPubMedGoogle Scholar
- 31.Fekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis TW, Shibre T, Teferra S, Tegegn T, Breuer E, Patel V, Tomlinson M, Thornicroft G, Prince M, Lund C (2015) Development of a scalable mental healthcare plan for a rural district in Ethiopia. Br J PsychiatryGoogle Scholar
- 33.Tsigebrhan R, Shibre T, Medhin G, Fekadu A, Hanlon C (2014) Violence and violent victimization in people with severe mental illness in a rural low-income country setting: a comparative cross-sectional community study. Schizophr Res 152(1):275–282. https://doi.org/10.1016/j.schres.2013.10.032 CrossRefPubMedGoogle Scholar
- 35.World Health Organization (2014) Mental health atlas. WHO Press, GenevaGoogle Scholar
- 37.Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, Petersen I, Bhana A, Kigozi F, Prince M, Thornicroft G, Hanlon C, Kakuma R, McDaid D, Saxena S, Chisholm D, Raja S, Kippen-Wood S, Honikman S, Fairall L, Patel V (2012) PRIME: a programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med 9(12):e1001359. https://doi.org/10.1371/journal.pmed.1001359 CrossRefPubMedCentralPubMedGoogle Scholar
- 39.Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, Ssebunnya J, Fekadu A, Shidhaye R, Petersen I (2014) Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low-and middle-income countries. PloS one 9(2):e88437CrossRefPubMedCentralPubMedGoogle Scholar
- 41.World Health Organization (2010) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental Health Gap Action Programme (mhGAP). World Health Organization, GenevaGoogle Scholar
- 42.WHO (2008) Mental Health Gap Action Programme Scaling up care for mental, neurological, and substance use disorders. WHO, GenevaGoogle Scholar
- 43.Rucker J, Newman S, Gray J, Gunasinghe C, Broadbent M, Brittain P, Baggaley M, Denis M, Turp J, Stewart R, Lovestone S, Schumann G, Farmer A, McGuffin P (2011) OPCRIT+: an electronic system for psychiatric diagnosis and data collection in clinical and research settings. Br J Psychiatry 199(2):151–155. https://doi.org/10.1192/bjp.bp.110.082925 CrossRefPubMedCentralPubMedGoogle Scholar
- 46.Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x CrossRefPubMedCentralPubMedGoogle Scholar
- 49.Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG (2001) AUDIT: the alcohol use disorders identification test: guidelines for use in primary health care. World Health Organization, GenevaGoogle Scholar
- 50.StataCorp (2015) Stata Statistical software: release 14. StataCorp LP. College Station, TXGoogle Scholar
- 51.Asher L, Fekadu A, Teferra S, De Silva M, Pathare S, Hanlon C (2017) “I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia. Globalization health 13(1):47. https://doi.org/10.1186/s12992-017-0273-1 CrossRefPubMedGoogle Scholar