Mental and physical health in Rwanda 14 years after the genocide

PurposeTo examine the socio-demographic determinants of post-traumatic stress disorder (PTSD) and its association with major depressive episode and self-perceived physical and mental health in a large random sample of the Rwandan population 14 years after the 1994 genocide.MethodsUsing the Mini International Neuropsychiatric Interview and Medical Outcomes Study 36-Item Short-Form (SF-36) translated in Kinyarwanda, we interviewed 1,000 adult residents from the five provinces of Rwanda. Socio-demographic data and specific somatic symptoms were also recorded. Data analysis included 962 questionnaires.ResultsParticipants were predominantly female (58.9%), aged between 16 and 34 years (53.2%), with a low level of education (79.7% below secondary school). Prevalence of PTSD was estimated to be 26.1%. In multivariable analysis, factors associated with PTSD were being aged between 25 and 34 years, living in extreme poverty, having endured the murder of a close relative in 1994, being widowed or remarried, having lost both parents and living in the South Province. Participants who fulfilled diagnostic criteria for PTSD were significantly more often affected with major depression (68.4 vs. 6.6%, P < 0.001) and substance dependence (7.6 vs. 3.5%, P = 0.013) than respondents without PTSD. They scored significantly lower on all SF-36 subscales. Somatic symptoms such as hiccups, fainting and loss of speech or hearing delineated a specific pattern of post-traumatic stress syndrome.ConclusionsPTSD remains a significant public health problem in Rwanda 14 years after the genocide. Facilitating access to appropriate care for all those who need it should be a national priority.

[1]  P. Fisher,et al.  Post-traumatic stress reactions among Rwandan children and adolescents in the early aftermath of genocide. , 2009, International journal of epidemiology.

[2]  G. Carrin,et al.  Mutual health insurance in Rwanda: evidence on access to care and financial risk protection. , 2011, Health policy.

[3]  R. Yehuda,et al.  Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors. , 1998, The American journal of psychiatry.

[4]  T. Hergueta,et al.  The mini international neuropsychiatric interview , 1998, European Psychiatry.

[5]  B. L. Cardozo,et al.  Mental health in complex emergencies , 2004, The Lancet.

[6]  A. Kleinman,et al.  Culture and depression. , 1986, The New England journal of medicine.

[7]  M. Zraly,et al.  Don't let the suffering make you fade away: an ethnographic study of resilience among survivors of genocide-rape in southern Rwanda. , 2010, Social science & medicine.

[8]  G. Apolone,et al.  The Italian SF-36 Health Survey: translation, validation and norming. , 1998, Journal of clinical epidemiology.

[9]  T. Elbert,et al.  Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors , 2011, European journal of psychotraumatology.

[10]  Zaid Chalabi,et al.  Optimization of household survey sampling without sample frames. , 2006, International journal of epidemiology.

[11]  R. Kessler,et al.  Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. , 2002, Psychiatric services.

[12]  A. Thompson,et al.  The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. , 2008, Clinical psychology review.

[13]  Carol A. Trujillo,et al.  The MOS 36-Item Short Form Health Survey: reliability, validity, and preliminary findings in schizophrenic outpatients. , 1998, Medical care.

[14]  M. Onyeama,et al.  Bipolar disorder in Enugu, South East Nigeria: demographic and diagnostic characteristics of patients. , 2010, Psychiatria Danubina.

[15]  T. Clausen,et al.  Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations , 2010, BMC medical research methodology.

[16]  H. Weinstein,et al.  Trauma and PTSD symptoms in Rwanda: implications for attitudes toward justice and reconciliation. , 2004, JAMA.

[17]  P. Bolton,et al.  PREVALENCE OF DEPRESSION IN RURAL RWANDA BASED ON SYMPTOM AND FUNCTIONAL CRITERIA , 2002, The Journal of nervous and mental disease.

[18]  L. Loutan,et al.  Transcultural Validity of a Structured Diagnostic Interview to Screen for Major Depression and Posttraumatic Stress Disorder Among Refugees , 2007, The Journal of nervous and mental disease.

[19]  T. Elbert,et al.  Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors , 2010, BMC psychiatry.

[20]  L. Kirmayer,et al.  Cultural Models and Somatic Syndromes , 2007, Psychosomatic medicine.

[21]  A. Dyregrov,et al.  Trauma Exposure and Psychological Reactions to Genocide Among Rwandan Children , 2000, Journal of traumatic stress.

[22]  I. Bramsen,et al.  Fifty years later: the long‐term psychological adjustment of ageing World War II survivors , 1999, Acta psychiatrica Scandinavica.

[23]  M. Koeter,et al.  The prevalence of mental health problems in Rwandan and Burundese refugee camps , 2000, Acta psychiatrica Scandinavica.

[24]  Barbara Gandek,et al.  Health and Quality of Life Outcomes , 2003 .

[25]  T. Elbert,et al.  Community-implemented trauma therapy for former child soldiers in Northern Uganda: a randomized controlled trial. , 2011, JAMA.

[26]  T. Perneger,et al.  The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation. , 1998, Journal of clinical epidemiology.

[27]  C. McHorney,et al.  The MOS 36‐Item Short‐Form Health Survey (SF‐36): II. Psychometric and Clinical Tests of Validity in Measuring Physical and Mental Health Constructs , 1993, Medical care.

[28]  T. Elbert,et al.  Prolonged Grief Disorder and Depression in Widows Due to the Rwandan Genocide , 2009, Omega.

[29]  P. Bolton.  Local perceptions of the mental health effects of the Rwandan genocide. , 2001, The Journal of nervous and mental disease.

[30]  J. Beckham,et al.  Post-traumatic stress disorder and smoking: a systematic review. , 2007, Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco.

[31]  S. Seubsman,et al.  Thai SF-36 health survey: tests of data quality, scaling assumptions, reliability and validity in healthy men and women , 2008, Health and quality of life outcomes.

[32]  R. Lewis‐Fernández,et al.  The cross‐cultural validity of posttraumatic stress disorder: implications for DSM‐5 , 2011, Depression and anxiety.

[33]  D. Sheehan,et al.  The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. , 1998, The Journal of clinical psychiatry.

[34]  L. Loutan,et al.  Mental and physical health of Kosovar Albanians in their place of origin: a post-war 6-year follow-up study , 2011, Social Psychiatry and Psychiatric Epidemiology.

[35]  C. Brewin,et al.  Delayed-onset posttraumatic stress disorder: a systematic review of the evidence. , 2007, The American journal of psychiatry.

[36]  Z. Solomon,et al.  Posttraumatic intrusion, avoidance, and social functioning: a 20-year longitudinal study. , 2007, Journal of consulting and clinical psychology.

[37]  T. Dalgleish,et al.  A dual representation theory of posttraumatic stress disorder. , 1996, Psychological review.

[38]  Dan J Stein,et al.  Validity of the K-10 in detecting DSM-IV-defined depression and anxiety disorders among HIV-infected individuals , 2009, AIDS care.

[39]  Y. Shen,et al.  Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalisation , 2003, Journal of epidemiology and community health.

[40]  M. Rowson,et al.  Innovations in Rwanda's health system: looking to the future , 2008, The Lancet.

[41]  P. Bovier,et al.  Screening for Major Depression and Posttraumatic Stress Disorder among Asylum Seekers: Adapting a Standardized Instrument to the Social and Cultural Context , 2006, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[42]  D. Hinton,et al.  Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide , 2003, Psychiatry Research.

[43]  A. Mitchell,et al.  Clinical diagnosis of depression in primary care: a meta-analysis , 2009, The Lancet.

[44]  J. Ware,et al.  Cross-cultural comparisons of the content of SF-36 translations across 10 countries: results from the IQOLA Project. International Quality of Life Assessment. , 1998, Journal of clinical epidemiology.

[45]  M. Ommeren,et al.  Common mental disorders in postconflict settings , 2003, The Lancet.

[46]  Z. Steel,et al.  Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. , 2009, JAMA.

[47]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .

[48]  Beverly J. Volicer,et al.  Biostatistics: A Foundation for Analysis in the Health Sciences , 1979 .